FAQ Directory: Health Plan Accreditation

Yes. The following updates to the Exceptions section language are effective immediately and will be included in a Policy Update in November 2023.
This element is NA if:

• The organization does not delegate UM activities.
• Delegation arrangements have been in effect for less than 12 months.

Factor 1 is NA for mail service delegates.
Factors 2–6 are NA for Interim Surveys.
Factors 3 and 4 are NA if a mail service delegate distributes information for an element with an annual frequency. The delegation agreement in Element A must outline the frequency for reviewing the delegate’s reports (i.e., annual or semiannual) (UM 13, Element A, factor 4).
Factors 5 and 6 are NA if the delegate only provides cloud-based UM data storage functions and does not provide services that create, modify or use UM data.
Factors 5 and 6 are NA for mail service delegates that:

• Provide print mail service only. 
• Do not have access to the organization’s UM system. 
• Do not have a UM system of their own.
• Do not modify or store the UM data sent by the organization. 
• Return UM data provided by the organization.

All bullets must be addressed in a delegation agreement for factors 5 and 6 to be NA.
Factor 6 is NA if the organization did not identify any date modifications or if all identified date modifications met the delegation agreement or the delegate’s policies and procedures.

Note: The strikethrough text indicates changes to the Exceptions section.

HP 2024

No. An organization that only provides print services is not considered a delegate or a vendor, and is outside the scope of NCQA requirements.

HP 2024

Yes. Using UM 13: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 13, Element A: Delegation Agreement

• Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution (e.g., UM 11, Element B (annual updates for pharmaceutical restrictions/preferences).
  • Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance, if applicable.
  • Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
• Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.

UM 13, Element C: Review of the UM Program:

• Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates.
• Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
  • Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).

Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit.  This must be specified in the delegation agreement.

Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.

HP 2024

NCQA requires practitioners to attest to their lack of present illegal drug use, but not to past drug use or history of drug use.

Organizations are not required to refer exclusively to the present; therefore, an organization may choose to ask about both present and past drug use.

HP 2024

No. Only addressing the UM denial notification to the provider does not meet the intent of the requirement. The UM denial notification must also be addressed to the attending/treating practitioner.

If information on the attending/treating practitioner was not provided with the request, the organization attempts to identify the practitioner and documents its efforts to identify the practitioner. If the organization is not able to obtain the name of the attending/treating practitioner, the practitioner’s name is not required. In such a case, the organization must address the notification "To the Attention of the Attending/Treating Practitioner.”

For urgent concurrent decisions, the organization may inform the hospital Utilization Review department staff without attempting to identify the attending/treating practitioner, with the understanding that staff will inform the practitioner.

In all cases, if the practitioner is not known, the organization must address the notification “To the Attention of the Attending/Treating Practitioner”; the practitioner’s name is not required.

HP 2023

Yes. Organizations may use an API to access data from a primary or approved source, and must provide documentation that the API collects information only from primary or approved sources.

Organizations that use an API must still meet the “Appropriate documentation” requirements in CR 1, Element A, including documentation that the organization's staff reviewed the information.

As noted in an FAQ from February 15, 2023, use of another entity’s software to collect credentialing information is not considered delegation unless the entity also reviews the information on the organization’s behalf.

HP 2023

Yes, if the delegation agreement addresses the required information in the Explanation (e.g., CR 8, Element A, factor 3 for credentialing). The delegation agreement must specify:

• How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
• What information is reported by the delegate in the delegate's system about the delegated activities.
• How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).

HP 2023

NCQA considers the following standards to be a delegation relationship if an organization uses a mail service organization to meet the distribution requirements:

• NET 4, Element A: Notification of Termination
• NET 4, Element B: Continued Access to Practitioners
• UM 5, Elements A, B, C: Timeliness of UM Decisions
• UM 7, Elements B, C, E, F, H, I: Denial Notices
• UM 9, Elements B, D: Appropriate Handling of Appeals
• UM 11, Element B: Pharmaceutical Restrictions/Preferences
• UM 11, Element C: Pharmaceutical Patient Safety Issues

HP 2023

As noted in the Glossary appendix, NCQA’s long-standing definition of “annual” is 12 months plus a 2-month grace period (12–14 months). “Grace period” refers to allowing organizations to complete an activity after it is due and not before it is due.

HP 2023

No. The use of another entity’s evidence-based content within the organization’s case management system is not considered delegation if the organization maintains control over how the content is used and can customize it as needed. The evidence used to support the content must be cited.

HP 2023

Yes. The following changes apply to the 2022 MA Deeming Module:

• MA 19, Element A:
  • Clarified that the organization’s delegation agreements for MA standards must include a statement requiring delegates to adhere to MA regulations.
• SNP 2, Element A:
  • Revised factor 3 to reference both initial and annual health risk assessments (HRAs).
  • Clarified in the explanation that the organization must conduct an initial and annual HRA using a comprehensive HRA tool and ensure that results are addressed in the member’s individualized care plan, as required under 422.101(f)(1)(ii).
• SNP 2, Element C:
  • Added factor 2: “The organization annually, and within the first 12 months of enrollment, conducts face-to-face encounters between the member and their care team.” The face-for-face encounter must be either in person or through visual, real-time, interactive telehealth.
  • Adjusted the scoring to reflect the new factor.
  • Revised the explanation to include “Factor 2: Face-to-face encounter” subhead and text. The encounter must be between the member and representative from any of the following:
    • The ICT.
    • The organization’s case management and coordination staff.
    • A health care provider contracted with the health plan.
• SNP 3, Element A:
  • Revised factor 5 to read: “Including the ICT, as outlined in SNP 2, Element C, to oversee the MOC’s evaluation and monitoring process.”
  • Revised the scope of review to clarify that the organization includes the ICT in the monitoring and evaluation process.
  • Replaced the “Factor 5: Appropriate personnel” subhead with “Factor 5: The ICT” and revised the explanation to read:
    • The organizational chart documents the organization’s reporting structure and staff responsible for administering the MOC program, including the ICT, as specified in SNP 2, Element C, factor 1. According to the defined MOC, the organization must use an ICT to manage member care. The ICT includes:
      • Practitioners with demonstrated expertise and training,
      • Training in a defined role appropriate to their licensure in treating individuals similar to the targeted population of the organization, as applicable.

HP 2022

No. The use of another entity’s software to collect credentialing information is not considered delegation unless the other entity also reviews the information on the organization's behalf. NCQA standards allow organizations to use software to collect credentialing information from approved sources, as long as organization staff document that the information was reviewed and verified.

HP 2023