Yes. Organizations may provide oral notification, followed by written/electronic notification within three calendar days.
UM_CR 2013
FAQ Directory: Utilization Management, Credentialing and Provider Network
Filter Results
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?
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?
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?
10.15.2013 Meeting UM 7C and 7F using the Notice of Denial of Medical Prescription Drug Coverage. Does the Notice of Denial of Medicare Prescription Drug Coverage meet the same factors in UM 7, Elements C and F as the Notice of Denial of Medical Coverage (NDMC)?
10.15.2013 Core and Structural elements. What is the difference between core elements and structural elements?
Core elements are requirements that an organization must meet even if it has no clients.
Structural elements are requirements that the organization must meet even if it delegates 100% of the function. If an organization delegates the functions associated with a structural requirement, it must provide NCQA with its own programs or policies and procedures and evidence of approval of the delegates documentation.
UM_CR 2013
7.15.2013 Using physician groups or IPAs to distribute information to practitioners If an organization contracts with a physician group or IPA, may the physician group or IPA distribute information to its practitioners if covered in the contract? Does NCQA consider this contractual arrangement to be delegation?
5.15.2013 National Student Clearinghouse as a source for education and training Does NCQA accept the National Student Clearinghouse (NSC) as a source for education and training?
The NSC is not recognized by NCQA as a source for education and training. However, the NSC would be considered an agent of the medical or professional school if the school has a contract with the Clearinghouse to provide verification services. The organization must provide documentation that the specific school has a contract with the Clearinghouse.
UM_CR 2013