Factors 7-13 should be scored as “Met” for upheld denials sent to MAXIMUS.
HP 2018
FAQ Directory: Health Plan Accreditation
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3.15.2019 UM 8, Element A MAXIMUS What factors are scored “Met” for UM 8, Element A if an upheld denial was sent to MAXIMUS?
3.15.2019 LTSS 4, Element C: Analysis of Unplanned transitions The explanation for LTSS 4, Element C, factor 1 states that analysis includes patterns of unplanned admissions, readmissions, emergency room visits and repeat visits, and admission to participating and nonparticipating facilities.
Is the organization required to include all these areas to meet the intent of the factor?
3.15.2019 Citing a benefit provision If a benefit provision is used as the basis for the denial, how must it be cited in the notification?
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
HP 2019
3.15.2019 PHM 5, Element F: Aligning the examples with the factor explanation Are the examples in PHM 5, Element F all-inclusive? Does using only the listed questions meet the requirement?
No. As a general rule, examples should be used as a guide. Examples of questions for PHM 5, Element F that are not prescriptive, but address each requirement listed in the Explanation, include:
1. How satisfied are you with the information provided about the overall case management program?
2. How would you rate your experience with the case manager overall? With the program staff?
3. Did the case manager and other program staff treat you with courtesy and respect?
4. Was the information provided to you useful?
5. How well were you able to follow the recommendations provided to you by the case manager?
6. Were you able to achieve your health goals in your case management plan?
HP 2019
2.15.2019 Language in denial letters May an organization send a single denial letter to a member and a practitioner that contains the reason for the denial in both layman terms (for the member) and clinical terms (for the practitioner)?
Yes. The organization may send a single letter to the member and practitioner that includes the specific reason for the denial, in language that would be easily understood by the member. The letter may also include, in a separate section, additional clinical or technical language directed toward a practitioner.
When NCQA reviews the letter to ascertain if the reason for the denial would be easy for the member to understand, it considers both the written reason and the context of the language and whether the information can be understood in context.
HP 2019
12.15.2018 Mutually Agreed-Upon Dates in the Delegation Contract What date on the delegation agreement is considered the “mutually agreed-upon” date?
NCQA considers the implementation date as the date when the delegate can start performing delegated activities. But because the organization and delegate may have mutually agreed on and implemented delegated activities before signing the delegation agreement, NCQA is changing the policy for evidence of the implementation date.
When reviewing a delegation agreement, NCQA will consider the effective date or start date specified in the agreement as the mutually agreed-upon implementation date, for Element A (of the delegation standards), factor 1. This date may be before or after the signature date on the delegation agreement. If the agreement does not contain an effective date/start date, NCQA considers the date when the agreement was signed as the mutually agreed-upon implementation date.
NCQA may also accept other evidence of the implementation date: a letter, meeting minutes or other form of communication between the organization and the delegate that references their agreement on the delegated activity start date.
If an organization references the effective date/start date of the delegation agreement as the implementation date, NCQA will require submitted evidence for all other delegation factors to conform to that date as the implementation date.
The language in the explanation will be updated in a future Policy Update for applicable 2019 publications.
HP 2019
10.15.2018 80% must-pass threshold for UM elements Because NCQA raised the UM must-pass threshold from 50% to 80%, will NCQA create an 80% scoring option for requirements without such a scoring option?
No. To keep scoring simple, NCQA set a threshold of 80% or higher for all UM must-pass elements, rather than setting a specific threshold for each element based on its scoring options. If an element does not have an 80% option, the “or higher” applies. Keep in mind that an organization may miss the requirements for a few files and still score 100% on the element. For additional information on file review scoring, refer to the scoring table in each element or to the file review worksheet in the Interactive Review Tool (IRT).
HP 2019
9.15.2018 Data collection for prevention programs for behavioral healthcare for QI 6, Element A, factor 5 For QI 6, Element A, factor 5, are organizations required to have implemented a preventive behavioral healthcare program in order to meet the factor?
No. Element A does not require organizations to implement a preventive behavioral healthcare program. The intent of factor 5 is that organizations collect data to determine if there are behavioral health issues that could be prevented if a program were to be implemented. Organizations collect data to meet Element A. Identifying the opportunity for such a program and implementing it is applicable to Element B.
HP 2019
9.15.2018 Life-planning activities for Complex Case Management (CCM) Policies and Assessment Are organizations required to address life-planning activities at the first contact and start of the CCM initial assessment?
No. After consideration, NCQA removed the requirement for case managers to address life-planning activities at the start of the initial assessment (first contact). This FAQ replaces the previous FAQ issued on October 15, 2017 (which has been deleted) regarding first contact, and the workbook has been adjusted to accommodate the change.
HP 2019
9.15.2018 Level of Analysis Required for Appointment Accessibility Does the organizational analysis in NET 2, Element A need to be stratified by practitioner type?
9.15.2018 Revised Look-back Period for UM 7, Elements C, F, I (factors 2 and 3) In the 2019 HPA Standards and Guidelines, NCQA added a fifth bullet to the factor 2 Explanation and revised the factor 3 Explanation in UM 7, Elements C, F and I. Will NCQA give organizations a grace period for the added information in factors 2 and 3 of UM 7, Elements C, F and I?
The intent of the added language in factors 2 and 3 was to clarify the minimum information required for expedited appeals. NCQA recognizes these are new requirements, and for this reason, has added the following language to the scope of review:
Organizations must implement the changes in factors 2 and 3 for files processed on or after 11/1/18.
NCQA will post an update in December for the 2019 HP publication to reflect this change.
HP 2019
9.15.2018 Terminated arrangements more than 90 calendar days before submission If an organization terminated an arrangement with an NCQA-Accredited/Certified/Recognized delegate more than 90 calendar days before it submitted the completed survey tool, is the organization eligible for automatic credit for the portion of the look-back period when activities were performed by the delegate?
Yes. For non-file review requirements, if the arrangement was terminated more than 90 calendar days before submission of the completed survey tool, the organization is eligible for automatic credit for the portion of the look-back period when the NCQA-Accredited/ Certified/Recognized delegate conducted activities. For file review requirements, automatic credit is applied if the delegate processed (or handled) the file, regardless of when the delegation arrangement was terminated.
HP 2019