FAQ Directory: Utilization Management, Credentialing and Provider Network

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8.15.2018 Updated: Use of Acronyms in UM Denial and Appeal Notices 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?

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.

UM_CR 2019

7.15.2018 Medical necessity review for personal care services Does NCQA require medical necessity review for personal care services, such as cooking, cleaning and transportation?

No. Medical necessity review is not required for personal care services and other activities of daily living in UM 4–UM 7. However, if these services are covered benefits, any denial decision may be appealed and is included in the scope of appeal file review for UM 9.

UM_CR 2018

11.15.2017 Updated: Timeliness of postservice appeal decisions for Medicare and Medicaid Does the recent change for Medicare and Medicaid postservice appeals from 60 calendar days to 30 calendar days align with Chapter 13 of the Medicare Managed Care Manual?

No. Medicare product lines continue to follow the 60-calendar-day time frame for postservice appeals.

Note: The requirement is correct for Medicare product lines; Medicaid product lines continue to follow the 30-calendar-day time frame for postservice appeals.

UM_CR 2018

9.15.2017 Denial Notices—Right to Representation The denial notification must include a statement that members may be represented by anyone they choose, including an attorney. If the notification states that members have the right to be represented by anyone, but does not specify “including an attorney,” is this acceptable?

Yes. If the notification indicates that members may be represented by anyone, this is acceptable because the reference to “anyone” implies “including an attorney.” If the notification lists specific types of individuals, it must also specify “an attorney.”

UM_CR 2018

9.15.2017 Utilization Management and Use of Voicemail When does voicemail meet UM notification requirements?

Voicemail meets UM requirements only when the organization notifies a practitioner about the opportunity to discuss a denial decision. The organization must document who left the message, along with the date and time it was left. Voicemail messages do not meet any other notification requirement.

UM_CR 2018

8.15.2017 Overturned appeals Who can overturn a medical necessity or benefit denial on appeal?

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

5.15.2017 Updated: Pharmacists as Same-or-Similar Specialists May pharmacists be considered “same-or-similar” specialists?

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

4.15.2017 UM 9B: Timeliness of the Appeal Process for Medicaid Under the new Medicaid Managed Care Final Rule, effective July 1, 2017, Medicaid organizations are required to have only one level of appeal. However, this may not be effective immediately for organizations with contracts prior to this date. How will NCQA evaluate Medicaid organizations coming through under the 2017 standards and guidelines?

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

3.15.2017 UM 9 C: Scoring reviewer for appeals of system-made benefit denials Under UM 9, Element C, for an appeal of an initial benefit denial that was made by an automated system (e.g., claims or POS), where a person makes the appeal decision, should the file be scored “NA” or “Yes”?

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

1.15.2017 UM 7 B: Specific criterion referenced in a denial decision In UM 7, Element B, factor 2, organizations are required to reference the specific criterion used to make a denial decision. How specific does the criterion need to be?

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

10.15.2016 Scoring organizations 100% for UM 4, Element H How are organizations scored for UM 4, Element H (UM 4, Element F in MBHO and UM-CR) under the 2016 Standards and Guidelines?

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

10.15.2016 Updated: Types of denials excluded from the UM 4H file-review universe What types of denials are excluded from file review for UM 4, Element H (UM 4F in UM-CR and MBHO)?

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