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FAQ Directory: Utilization Management, Credentialing and Provider Network

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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

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

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)?

Yes. NCQA accepts the Notice of Denial of Medical Prescription Drug Coverage as meeting factors 1-3 of these elements.

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?

The physician group or IPA may distribute information to its physicians if this language is in the contractual agreement. NCQA does not consider this to be delegation. The organization must provide the required information to the physician group or IPA.

UM_CR 2013

5.15.2013 When ER files are included in the universe of files for review When are ER denial files included in the universe of files for file review during an Accreditation or Certification Survey?

Generally, ER denials are not included in the universe of files for initial UM decisions unless a denial is appealed. In that case, the ER appeal is included in the universe of files for appeals.

UM_CR 2013

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

4.15.2013 Scoring for CRC 2, Element C: Agreement and Collaboration with Health Plans How is CRC 2, Element C scored for organizations that may not have a delegation agreement in place?

Element C is scored "NA" for organizations that do not have a delegation agreement, and there is no reporting to the client.

UM_CR 2013