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HP 2020
FAQ Directory: Health Plan Accreditation
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8.24.2018 What is the price for the LTSS Distinction for Health Plans?
8.24.2018 How long does it take to earn LTSS Distinction for Health Plans?
8.24.2018 Where can I find the Medicaid Module Standards and Guidelines? How can I obtain the Medicaid Module Standards and Guidelines?
8.24.2018 How long does it take to earn Health Plan Accreditation?
8.24.2018 What is the price for Health Plan Accreditation?
8.24.2018 Where can I find the Health Plan Accreditation Standards and Guidelines?
Find the Standards and Guidelines document in the NCQA eStore.
HP 2020
8.17.2018 Where can I find information to help me get started with the LTSS Distinction?
- Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation.
- Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review.
- Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organization’s survey readiness—the tool calculates your potential survey score.
HP 2020
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.
HP 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?
5.15.2018 MED standards and the new Medicaid module The previous MED standards are now 15 standards. Can you explain what happened?
In March, NCQA released an expanded Medicaid Module, a voluntary set of 15 standards for organizations with a Medicaid product line. This new module both incorporated the original MED standards (MED 1-MED 6) and added 10 new standards to align with provisions in the federal Medicaid Managed Care Final Rule released by CMS in April 2016.
The new MED module applies to only 2018 HPA; therefore, HPA survey tools for 2017 and earlier are unaffected and do not include the new Medicaid module.
HP 2018
2.15.2018 Identifying a member for Complex Case Management When is a member identified as eligible to receive complex case management services?
A member is identified to receive complex case management services in PHM 2, Element D. The organization’s policies and procedures describes its method for categorizing membership for involvement in complex case management. Once identified, the organization must begin the initial assessment within 30 days and complete within 60 days to meet the PHM 5, Element D requirement.
HP 2018