Interpret that text to mean any combination of high and medium other than the scoring thresholds specified for “MET.”
For example, an organization must earn “high” on 7 factors to score MET on PHM 5, Element D; therefore, to score “PARTIALLY MET” for that element, it may earn “high” on 0–6 factors and “medium” on the remaining factors.
HP 2020
Yes, it is correct. The elimination of Elements A, C and E does not affect the review of Element D: UM Timeliness Report. The expectation is that the report includes timeliness for both decision making and notification of the decision given that the report includes denials and approvals. NCQA does not require written notification for approvals; therefore, timeliness for approvals is only reported under decisions.
HP 2020
NCQA does not evaluate the validity or reliability of the measure in Element A, QI 3 and QI 4. In Element C, QI 3 and QI 4, NCQA evaluates the validity of the remeasurement relative to the initial measurement. For example, NCQA evaluates if sampling, timing or other methodological factors introduces bias or other issues of comparison when determining an intervention’s effectiveness.
HP 2020
The purpose of same-or-similar specialist review of appeals is to apply specific clinical knowledge and experience when determining if an appeal meets criteria for medical necessity and clinical appropriateness. “Training and experience” refers to the practitioner’s clinical training and experience.
The intent is that the specialist reviewing the appeal would have encountered a patient with this condition who is considering or has received the service or procedure in a clinical setting. NCQA assesses whether the specialist is appropriate for the condition, service or procedure in question, and does not consider the referring practitioner type.
Effective January 1, 2020, NCQA accepts board certification in the same specialty as a proxy for clinical training and experience.
NCQA does not require that the same-or similar specialist reviewer be actively practicing.
Experience with the condition, service or procedure that is limited to UM decision making in cases similar to the appeal in question is not considered sufficient experience, nor do UM decision-making criteria supersede the requirement for same-or-similar specialist review.
HP 2020
For PHM 1, Element B, NCQA evaluates communicating information to members who become eligible for programs that involve interactive contact.
Therefore, for any program that involves interactive contact (e.g., CCM, wellness coaching, web-based tools, disease management, smoking cessation classes), if the organization under review (e.g., a plan) contracts with another organization (e.g., a PHM company) to perform the function and the PHM company is responsible for communicating the information required to meet PHM 1, Element B, the plan has delegated the functions associated with PHM 1, Element B. This is considered delegation and all delegation requirements, including oversight, apply.
If the PHM company provides a technology supported service, such as a web-based tool, this is a vendor relationship for any requirements that directly evaluate the PHM function (e.g., PHM 4).
HP 2020
The structure of Accreditation scoring is changing, beginning with Health Plan Accreditation 2020 and the 2020 HEDIS reporting year, when Accreditation and Health Plan Ratings will align. All organizations undergoing annual reevaluation in 2020 are included in the change to Ratings.
The links below provide information on the Health Plan Ratings, including the measures required for 2020 Accreditation.
Visit https://www.ncqa.org/wp-content/uploads/2019/07/20190731_2020_Health_Plan_Ratings_Methodology.pdf for information on the HPA Methodology document.
Visit https://www.ncqa.org/programs/health-plans/health-plan-accreditation-hpa/current-customers/hpa2020/scoring-updates/ for information on scoring updates.
Visit https://www.ncqa.org/wp-content/uploads/2019/05/2020-HP-Accreditation_HEDIS-CAHPS-Measures.pdf for the link to the HEDIS and CAHPS measures list for 2020
HP 2020
For Element A
For Element B
NCQA will clarify these requirements in the November Policy Update.
HP 2020
NCQA does not require a Credentialing Committee size, composition or quorum beyond that the committee must include practitioners who participate in the network.
Participating practitioners on the credentialing committee must be from a range of specialties or departments that represent the types of practitioners reviewed by the committee. For example, it would not be sufficient for only primary care practitioners to participate on the committee unless the network has only primary care practitioners.
HP 2020
