FAQ Directory: Utilization Management, Credentialing and Provider Network

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10.15.2016 Types of pharmacy point of service claims included in UM 4, Element H file review What types of pharmacy point of service claims should be included in the scope of UM 4, Element H (UM 4, Element F in MBHO and UM-CR)?

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

10.06.2016 Updated: Types of files included in the UM 4H file-review universe What types of files are included in file review for UM 4, Element H (UM 4F in UM-CR and MBHO)?

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

5.20.2016 UM 4, Element H File Review Does UM 4, Element H file review include benefit denials that resulted from the UM medical necessity review process?

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

5.20.2016 UM 4, Element H File Review and Medical Necessity Denials Are medical necessity denials included in the UM 4, Element H file review?

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

4.15.2016 Experimental/investigational procedure denials in UM 4H Are denials of requests for experimental or investigational procedures included in the file review for UM 4, Element H (UM 4F in UM-CR and MBHO)?

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

4.15.2016 Off-label medication use denials in UM 4H Are denials for “off-label” medication use included in the file review for UM 4, Element H (UM 4F in UM-CR and MBHO)?

Yes. Denials for off-label medication use are included in the scope of UM 4, Element H (UM 4F in UM-CR and MBHO) if the organization covers medications only for “on-label” use.

UM_CR 2016

3.15.2016 Review process versus review outcome Does the type of review (i.e., medical necessity, benefit or other) determine if a denial is included in the file-review universe for UM 4, Element H (UM 4F in UM-CR and MBHO)?

No. The outcome (reason for the denial) determines which files are included. If the decision is not made on the basis of medical necessity, but on the basis of a benefit or an administrative limitation, the file is included in the scope of UM 4, Element H (UM 4F in UM-CR and MBHO).

UM_CR 2016

12.18.2015 Automatic credit for UM pharmacy elements May health plans receive automatic credit for the new UM pharmacy elements if they delegate to organizations accredited or certified under standards years prior to 2016?

Organizations seeking accreditation or certification in UM under the 2016 standards may receive automatic credit for updating delegation agreements prior to survey tool submission, to include:

  • The new pharmacy requirements (UM 5, Elements E and F; UM 6, Element C; and UM 7, Elements G–I included in the 2016 Standards and Guidelines for the Accreditation of Health Plans) as delegated activities.
  • The requirement for delegates to provide separate UM pharmacy files for review.

Updates may be made to the delegation agreement, to an addendum or in other binding communication between the organization and the delegate. 

UM_CR 2016

10.15.2015 Oral notification of expedited appeal decisions UM 5 allows organizations to provide initial oral notification for urgent requests, with written notification within three calendar days. Does this also apply to expedited appeal decisions in UM 9, Element B?

Yes. Organizations may provide oral notification, followed by written/electronic notification within three calendar days.

UM_CR 2013

9.15.2015 Acceptable Documents for Policies and Procedures Many scopes of review in the standards require policies and procedures. How does NCQA define “policies and procedures” and what are acceptable documents?

Policies and procedures are official documents that describe business rules and a course of actions, and the methods for carrying out the actions. Simply put, policies and procedures specify how an organization performs the requirement under review—the organization’s “documented process.”
Usually, NCQA expects the organization to present only the components of the policies and procedures that demonstrate it meets the requirement. Depending on the element, this may include, but is not limited to, a program description, operating guidelines or process flowchart. 

 

UM_CR 2013

1.15.2015 Permitting practitioner’s review of UM denials with administrative licenses May practitioners with a current administrative license review denials of care based on medical necessity?

Yes. NCQA allows practitioners with a current administrative license to review denials of care based on medical necessity if the state issues administrative licenses that permit review of UM medical necessity cases.

UM_CR 2013

1.15.2014 Board Certification as Verification of Education and Training for Nurse Practitioners (NP) and Physician Assistants (PA) Is it acceptable to use ANCC and NCCPA board certification as verification of highest level of education for nurse practitioners and physician assistants?

Yes, if the organization can obtain written confirmation from the ANCC and NCCPA that they perform primary-source verification of the professional school training.

UM_CR 2013