No, notification of denials to a member through a web portal does not meet the requirement for member notifications. However, emailing a denial notification directly to a member would be acceptable for electronic notification.
MBHO 2020
FAQ Directory: Managed Behavioral Healthcare Organization Accreditation
Filter Results
1.15.2020 Denial Notifications to members via web portals If an organization uses a member web portal as a means of member written/electronic denial notification (which includes all requirements of UM 4 through UM 7), does this meet the UM denial notification requirements?
12.15.2019 Excluding organization employees and their dependents from complex case management (CCM) file review Should organizations exclude employees and their dependents from the CCM file review universe?
10.15.2019 CR 2, Element A, Factor 1 What is the required composition of the Credentialing Committee?
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.
MBHO 2020
10.15.2019 PHM 5: Assessment and Evaluation Does a combined summary of all factors in the assessment meet the requirement for documenting the conclusion of the initial assessment for PHM 5, Elements D and E?
Yes. Assessment and evaluation each require a case manager or a qualified individual to draw and document a conclusion about the data or information collected. Raw data or answers to questions do not meet the requirement; there must be a documented summary of the meaning or implications to the member’s situation, so data can be used in the case management plan.
The organization must draw a conclusion for each factor (unless otherwise stated in the explanation). This may be in separate summaries for each factor or in a combined summary, or in a combination of these.
MBHO 2019
10.15.2019 CR 7, Elements D and E: Assessing Medical and Behavioral Healthcare Providers Does NCQA require a separate tracking mechanism or report for each provider?
8.15.2019 Scoring UM File Review workbook for UM 5 timeliness Requirements Since UM 5, Elements A, C and E decision timeliness requirements were retired for 2020, how will the file review workbook be completed for those elements for 2019?
Because of the complexities of the workbook formulas, we are unable to change the workbook to accept “NA” in time for 2019 Standards Year surveys. To correctly calculate the notification date scoring, a date must be entered in this field.
NCQA will not require organizations to provide documentation of the decision date and will instruct surveyors to enter the earliest of
- The written notification date(s), or
- The verbal notification date(s) (if applicable).
Regardless of the score calculated for decision date,
- Surveyors will not score 30 files for this factor (although if it is necessary to review 30 files for the notification date, surveyors may need to complete this field, as described above for additional files).
- Surveyors will score the element NA in IRT.
MBHO 2019
8.15.2019 UM 5 Timeliness Requirements The UM 5, Elements A, C, E timeliness requirements were retired in 2020 Health Plan Accreditation. These requirements will be scored NA in HPA 2019. How will this affect timeliness reporting in UM 5, Element G?
8.15.2019 Scoring UM 5 Timeliness Requirements The UM 5, Elements A, C, E timeliness requirements were retired in 2020 Health Plan Accreditation. These requirements will be scored NA in HPA 2019. Does that mean that the “Explanation” and the “Related information” sections of these elements regarding notifications no longer apply to UM 5, Elements B, D and F?
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
MBHO 2019
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?
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.
MBHO 2019