FAQ Directory: Utilization Management, Credentialing and Provider Network

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10.16.2018 Because NCQA raised the UM must-pass threshold from 50% to 80%, will NCQA create an 80% scoring option for requirements without such a scoring option?

80% must-pass threshold for UM elements

No. To keep scoring simple, NCQA set a threshold of 80% or higher for all UM must-pass elements, rather than setting a specific threshold for each element based on its scoring options. If an element does not have an 80% option, the “or higher” applies. Keep in mind that an organization may miss the requirements for a few files and still score 100% on the element. For additional information on file review scoring, refer to the scoring table in each element or to the file review worksheet in the Interactive Review Tool (IRT).

9.15.2018 In the 2019 HPA Standards and Guidelines, NCQA added a fifth bullet to the factor 2 Explanation and revised the factor 3 Explanation in UM 7, Elements C, F and I. Will NCQA give organizations a grace period for the added information in factors 2 and 3 of UM 7, Elements C, F and I?

Revised Look-back Period for UM 7, Elements C, F, I (factors 2 and 3)

The intent of the added language in factors 2 and 3 was to clarify the minimum information required for expedited appeals. NCQA recognizes these are new requirements, and for this reason, has added the following language to the scope of review:

Organizations must implement the changes in factors 2 and 3 for files processed on or after 11/1/18.

NCQA will post an update in December for the 2019 HP publication to reflect this change.

9.15.2018 In UM 7, Elements B, E and H and UM 9, Element D, the explanation under Factor 1: states that the reason for denial should not include abbreviations or acronyms that are not defined. Similar language is in UM 8 A. Does this mean that they must be spelled out (e.g., “We are denying your request for a deoxyribonucleic acid (DNA) test because…”) or explained (“We are denying your request for a DNA test, which is a test that looks at your genetic information in order to…”), or both?

Updated: Use of Acronyms in UM Denial and Appeal Notices

The intent of the requirement is that the denial or appeal notice be written in language that can be easily understood by members. Because abbreviations/acronyms may include terms that are not easily understood, even when spelled out, they must be explained. NCQA is updating the explanation under each applicable factor of the referenced elements to read:

The denial [appeal] notification states the reason for the denial [upholding the denial] in terms specific to the member’s condition or request and in language that is easy to understand, so the member and practitioner understand why the organization denied the request [upheld the denial] and have enough information to file an appeal.
 
An appropriately written notification includes a complete explanation of the grounds for the denial, in language that a layperson would understand, and does not include abbreviations, acronyms or health care procedure codes that a layperson would not understand. The organization is not required to spell out abbreviations/acronyms if they are clearly explained in lay language. Denial [Appeal] notifications sent only to practitioners may include technical or clinical terms.
 

NCQA will post an update in December for the 2018 and 2019 HP and UM-CR-PN and 2018 MBHO publications to reflect this change.

9.15.2018 If an organization terminated an arrangement with an NCQA-Accredited/Certified/Recognized delegate more than 90 calendar days before it submitted the completed survey tool, is the organization eligible for automatic credit for the portion of the look-back period when activities were performed by the delegate?

Terminated arrangements more than 90 calendar days before submission

Yes. If the arrangement was terminated more than 90 calendar days before submission of the completed survey tool, the organization is eligible for automatic credit for the portion of the look-back period when the NCQA-Accredited/Certified/Recognized delegate conducted activities.

8.28.2018 Where can I find the Utilization Management Standards and Guidelines?

8.28.2018 What organizations are eligible for Utilization Management Accreditation?

Utilization Management Accreditation is for organizations that provide full scope utilization management services. Eligible organizations:

  • Must not be licensed as an HMO, POS, PPO or EPO.
  • Must not be eligible for NCQA Accreditation as a health plan or an MBHO.
  • Must perform utilization management functions directly or through a contract.
  • Must perform utilization management activities for at least 50% of the members.
Note: “Members” refers to membership of clients and organizations.

8.28.2018 Where can I find information to help me get started with Utilization Management Accreditation?

8.28.2018 How do I get started with Utilization Management Accreditation?

If you are not currently accredited and want to learn more, contact NCQA. If you are currently accredited and want to talk to someone about your status or about renewing or adding accreditations, submit a question through My NCQA.

8.28.2018 How long does it take to earn Utilization Management Accreditation?

The typical evaluation time frame is 12 months from application submission to decision, depending on an organization’s readiness. Some organizations may already be working within NCQA guidelines.

8.28.2018 What is the price for Utilization Management Accreditation?

Pricing is based on multiple factors. Obtain full pricing information by submitting a request through My NCQA.

8.28.2018 What is the process for earning Utilization Management Accreditation?

The first step to earning accreditation is a discussion with an NCQA program expert. Purchase and review the program resources, conduct a gap analysis and submit your online application.

Align your organization’s processes with the utilization management standards. NCQA conducts the survey and determines your accreditation status within 30 days of the final review.

8.28.2018 What are the Utilization Management Accreditation requirements?

Utilization Management Accreditation assesses an organization’s performance in the following areas:

  • Improving operations through an internal QI process
  • Ensuring appropriate agreements and collaboration with clients
  • Maintaining member confidentiality
  • Ensuring involvement of appropriate professionals
  • Making fair and timely decisions
  • Handling member appeals in a fair and timely manner
  • Measuring member and provider experience

 
To see all program requirements, get the Standards & Guidelines document.