FAQ Directory: Utilization Management, Credentialing and Provider Network

Yes. NCQA posted guidance for HEDIS reporting and Accreditation/Recognition programs at https://www.ncqa.org/covid/. NCQA is monitoring the effects of the coronavirus on our customers; we will adjust requirements as circumstances warrant. Please continue to check this website frequently as the situation continues to evolve.

UM_CR 2019

No. Except as noted under “Related information: Extending the recredentialing cycle length,” where NCQA makes provisions for situations such as active duty military assignment and medical leave, the organization may not extend the 36-month recredentialing cycle. If the practitioner is not recredentialed within 36 months, the file will be scored down. There is no grace period for recredentialing.
If an organization missed the recredentialing deadline and intends to keep the practitioner in the network, files must be processed as follows:

• If the organization can complete the credentialing process within 30 days of the original due date, it may recredential the practitioner (e.g., the organization need not verify credentials required only at initial credentialing). The organization must complete the process and make the credentialing decision within 30 days of the original credentialing due date.
• If the organization cannot complete the credentialing process within 30 calendar days of the original recredentialing due date, it must take the practitioner through the initial credentialing process.

UM_CR 2019

Yes, it is correct. The elimination of Elements A, C and E does not affect the review of Element D: UM Timeliness Report. The expectation is that the report includes timeliness for both decision making and notification of the decision given that the report includes denials and approvals. NCQA does not require written notification for approvals; therefore, timeliness for approvals is only reported under decisions.

UM_CR 2020

The purpose of same-or-similar specialist review of appeals is to apply specific clinical knowledge and experience when determining if an appeal meets criteria for medical necessity and clinical appropriateness. “Training and experience” refers to the practitioner’s clinical training and experience.
The intent is that the specialist reviewing the appeal would have encountered a patient with this condition who is considering or has received the service or procedure in a clinical setting. NCQA assesses whether the specialist is appropriate for the condition, service or procedure in question, and does not consider the referring practitioner type.

Effective January 1, 2020, NCQA accepts board certification in the same specialty as a proxy for clinical training and experience.
NCQA does not require that the same-or similar specialist reviewer be actively practicing.

Experience with the condition, service or procedure that is limited to UM decision making in cases similar to the appeal in question is not considered sufficient experience, nor do UM decision-making criteria supersede the requirement for same-or-similar specialist review.
 

UM_CR 2020

No, notification of denials to a member through a web portal does not meet the requirement for member notifications. However, emailing a denial notification directly to a member would be acceptable for electronic notification.

UM_CR 2020

NCQA does not require a Credentialing Committee size, composition or quorum beyond that the committee must include practitioners who participate in the network.
Participating practitioners on the credentialing committee must be from a range of specialties or departments that represent the types of practitioners reviewed by the committee. For example, it would not be sufficient for only primary care practitioners to participate on the committee unless the network has only primary care practitioners.

UM_CR 2020

No. The organization must provide documentation of a tracking mechanism—or mechanisms (e.g., checklist or spreadsheet)—that encompass the required provider types

UM_CR 2019

An “NA” score for UM 5, Elements, A, C and E will not affect the review of UM 5, Element G: UM Timeliness Report. However, NCQA still requires organizations to monitor and submit a report of timeliness of decision making and notification of decisions for UM 5, Element G.

UM_CR 2019

No. The “Explanation” and the “Related information” sections of UM 5, Elements A, C and E still apply to UM 5, Elements B, D and F, respectively. All applicable information was moved to the relevant elements for HPA 2020.

UM_CR 2019

Because of the complexities of the workbook formulas, we are unable to change the workbook to accept “NA” in time for 2019 Standards Year surveys. To correctly calculate the notification date scoring, a date must be entered in this field.
NCQA will not require organizations to provide documentation of the decision date and will instruct surveyors to enter the earliest of

1. The written notification date(s), or
2. The verbal notification date(s) (if applicable).

Regardless of the score calculated for decision date,

1. Surveyors will not score 30 files for this factor (although if it is necessary to review 30 files for the notification date, surveyors may need to complete this field, as described above for additional files).
2. Surveyors will score the element NA in IRT.

UM_CR 2019

Referencing benefit documents such as the member handbook or Certificate of Coverage by title alone is not specific enough to meet the requirement. Because benefit documents are often large and complex, the organization must direct members to the specific location of the information, either by section title or page number.

The reference must still support the organization’s decision and relate to the reason for the request

UM_CR 2019

Factors 7-13 should be scored as “Met” for upheld denials sent to MAXIMUS.

UM_CR 2018