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MBHO 2019
FAQ Directory: Managed Behavioral Healthcare Organization Accreditation
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8.24.2018 What is the price for Managed Behavioral Healthcare Accreditation?
8.24.2018 What is Managed Behavioral Healthcare Organization Accreditation?
NCQA Managed Behavioral Healthcare Organization Accreditation is a comprehensive, evidence-based evaluation that reviews organizations to assure they use processes to deliver high-quality care and access. It provides a framework for organizations to align and improve operations in areas of quality improvement, care coordination, utilization management and credentialing and recredentialing and members’ rights.
MBHO 2019
8.24.2018 How does MBHO Accreditation help my organization?
- Managed Behavioral Healthcare Organization Accreditation:
- Provides a framework for internal quality improvement in:
- Quality Management and Improvement.
- Care Coordination.
- Utilization Management.
- Credentialing and Recredentialing.
- Members’ Rights and Responsibilities.
- Elevates your organization’s status in the marketplace.
- Improves contracting opportunities.
- Satisfies health plan requirements.
MBHO 2019
8.24.2018 What are Managed Behavioral Healthcare Accreditation requirements?
The standards, provide a framework for implementing best practices to improve:
- Quality Management and Improvement: Monitor, evaluate and improve the quality and safety of care.
- Care Coordination: Coordinate medical care and behavioral healthcare for its members.
- Utilization Management: Notifies members and practitioners about coverage decisions within required time frames.
- Credentialing and Recredentialing: Verifies the credentials of the practitioners in its network.
- Members’ Rights and Responsibilities: Written members’ rights and responsibilities policy exist.
To see the program requirement details, get the Standards & Guidelines document.
MBHO 2019
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.
MBHO 2019
9.15.2017 Denial Notices—Right to Representation The denial notification must include a statement that members may be represented by anyone they choose, including an attorney. If the notification states that members have the right to be represented by anyone, but does not specify “including an attorney,” is this acceptable?
9.15.2017 Utilization Management and Use of Voicemail When does voicemail meet UM notification requirements?
Voicemail meets UM requirements only when the organization notifies a practitioner about the opportunity to discuss a denial decision. The organization must document who left the message, along with the date and time it was left. Voicemail messages do not meet any other notification requirement.
MBHO 2018
9.15.2017 Complex Case Management When does the time frame for completing the initial assessment for complex case management begin?
The time frame for completing the initial assessment begins when the member is determined to be eligible for complex case management. A member is eligible once identified using criteria from Element B, factor 2 and data sources in Element C (e.g., claims/encounter data, hospital discharge data). The initial assessment is not used to determine eligibility, although information gathered in the assessment may make a member ineligible.
Note: There is no “opt-in” option for identifying members.
MBHO 2017
8.15.2017 Overturned appeals Who can overturn a medical necessity or benefit denial on appeal?
5.15.2017 QI 5 Element G: Complex Case Management Assessment and Evaluation Is collecting information or data only for each factor sufficient to meet the “assessment” or “evaluation” requirements in QI 5, Element G (QI 9, Element G in MBHO)?
5.15.2017 Updated: Pharmacists as Same-or-Similar Specialists May pharmacists be considered “same-or-similar” specialists?
No. Beginning with files processed on and after February 1, 2017, pharmacists are not considered same-or-similar specialists because they do not treat patients in most instances.
Note: An FAQ communicating that pharmacists are not considered same-or-similar specialists was posted on October 15, 2016, and this policy was applied beginning February 1, 2017 (90 days from notification).
MBHO 2017
4.15.2017 UM 9B: Timeliness of the Appeal Process for Medicaid Under the new Medicaid Managed Care Final Rule, effective July 1, 2017, Medicaid organizations are required to have only one level of appeal. However, this may not be effective immediately for organizations with contracts prior to this date. How will NCQA evaluate Medicaid organizations coming through under the 2017 standards and guidelines?
Organizations with one level of appeal will be evaluated against the timeliness requirements specified in the current 2017 standard. Medicaid organizations that maintain a two-level appeal process will be evaluated under the 2016 standard requirements; these time frames apply:
- For preservice first-level appeals: 30 calendar days.
- For postservice first-level appeals: 60 calendar days.
MBHO 2017