FAQ Directory: Utilization Management, Credentialing and Provider Network

NCQA allows any individual at the organization to overturn a denial on appeal. Upheld denials still require same-or-similar specialist review for medical necessity decisions and review by a nonsubordinate for benefit decisions.

UM_CR 2018

No. Beginning with files processed on and after February 1, 2017, pharmacists are not considered same-or-similar specialists because they do not treat patients in most instances.
Note: An FAQ communicating that pharmacists are not considered same-or-similar specialists was posted on October 15, 2016, and this policy was applied beginning February 1, 2017 (90 days from notification).

UM_CR 2017

Organizations with one level of appeal will be evaluated against the timeliness requirements specified in the current 2017 standard. Medicaid organizations that maintain a two-level appeal process will be evaluated under the 2016 standard requirements; these time frames apply:

• For preservice first-level appeals: 30 calendar days.
• For postservice first-level appeals: 60 calendar days.

UM_CR 2017

The file should be scored "Yes.” A person making the appeal decision is different from, and not subordinate to, an automated system.

UM_CR 2017

The criterion referenced must be identifiable by name and must be specific to an organization or source (e.g., ABC PBM’s Criteria for Treatment of Hypothyroidism with Synthroid or CriteriaCompany Inc.’s Guidelines for Wound Treatment). If it is clear that the criterion is attributable to the organization, it is acceptable to state “our Criteria for XXX” (e.g., our Criteria for Treating High Cholesterol with Lipitor).

Note: This also applies to Element E and Element H in HPA and Element E in UM-CR.

UM_CR 2016

The following types of denials are excluded from the file review for UM 4, Element H (UM 4F in UM-CR and MBHO):

• Denials based on medical necessity.
• Postservice payment disputes where the member is not at financial risk.
• Denials by the secondary insurance organization, based on coordination of benefits, when the member has not filed a claim with the primary insurance.
• Denials of vision, dental or alternative/complementary medicine services not included in the member’s medical benefits or included as a rider.
• Denials of duplicate claims, even if there are other reasons for the denial.
• Denials of claims for the following reasons:
  • A service included in a bundled or case rate that is incorrectly billed separately.
  • Incorrect or missing provider billing information (e.g., tax ID).
  • The member was not eligible on the date of service.
  • Nonexistent CPT or ICD code.

UM_CR 2016

The following denials (rejections) are included in the scope of UM 4, Element H (UM 4, Element F in MBHO and UM-CR):

• Claims for prescriptions that were refilled too soon.
• Claims for prescriptions with the incorrect dosage or quantity.*
• Claims that were denied because the organization’s reasonable filing procedures were not followed (e.g., lack of prior authorization).

* Inaccurately filed claims that were rejected because of incorrect dosage or quantity may be considered pending until a decision is made. If the request is denied, the claim is included in the scope of UM 4, Element H.

UM_CR 2016

For the 2016 standards year, NCQA evaluates and scores the UM 4, Element H file review as normal during the onsite survey.
The final score will be adjusted, after the onsite survey, to 100% if the organization includes all denials required by UM 4, Element H in the file review universe. 
If the organization does not include all denials in the file review universe, NCQA will adjust the organization's final score to 50% for the 2016 standards year and 0% thereafter.
 

UM_CR 2016

The following types of denials are included in file review for UM 4, Element H (UM 4F in UM-CR and MBHO):

• Denials based on benefits that underwent a medical necessity review, which determined there was a benefit exclusion.
• Denials based on failure to follow the organization’s reasonable filing procedures. (i.e., lack of timely filing, lack of prior authorization).
• Auto-adjudicated claims denials or point of service (POS) claim denials that were not based on medical necessity (excluding duplicate claims).
• Denials not listed above that are not based on medical necessity, such as reversals or prior decisions due to fraud or improper billing.

UM_CR 2016

No. If an organization inadvertently includes a medical necessity denial in the UM 4H benefit denial file review, NCQA verifies that the file is appropriately classified as a medical necessity denial. If so, NCQA scores the file NA. If not, NCQA reviews the files under the benefit denial requirements of UM 4H.
 

UM_CR 2016

Yes. If an organization inadvertently includes a benefit denial in the UM 4–UM 7 medical necessity denial file reviews, NCQA verifies that the file is appropriately classified as a benefit denial. If so, NCQA scores the file NA. If not, NCQA reviews the files under the medical necessity denial requirements of UM 4–UM 7.

UM_CR 2016

Yes. If an experimental or investigational procedure is explicitly excluded from the benefits or medical policy, this is a benefit denial and is included in the scope of UM 4, Element H (UM 4F in UM-CR and MBHO).

UM_CR 2016