Factors 7-13 should be scored as “Met” for upheld denials sent to MAXIMUS.
UM_CR 2018
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.
UM_CR 2019
NCQA considers the implementation date as the date when the delegate can start performing delegated activities. But because the organization and delegate may have mutually agreed on and implemented delegated activities before signing the delegation agreement, NCQA is changing the policy for evidence of the implementation date.
When reviewing a delegation agreement, NCQA will consider the effective date or start date specified in the agreement as the mutually agreed-upon implementation date, for Element A (of the delegation standards), factor 1. This date may be before or after the signature date on the delegation agreement. If the agreement does not contain an effective date/start date, NCQA considers the date when the agreement was signed as the mutually agreed-upon implementation date.
NCQA may also accept other evidence of the implementation date: a letter, meeting minutes or other form of communication between the organization and the delegate that references their agreement on the delegated activity start date.
If an organization references the effective date/start date of the delegation agreement as the implementation date, NCQA will require submitted evidence for all other delegation factors to conform to that date as the implementation date.
The language in the explanation will be updated in a future Policy Update for applicable 2019 publications.
UM_CR 2019
No. To keep scoring simple, NCQA set a threshold of 80% or higher for all UM must-pass elements, rather than setting a specific threshold for each element based on its scoring options. If an element does not have an 80% option, the “or higher” applies. Keep in mind that an organization may miss the requirements for a few files and still score 100% on the element. For additional information on file review scoring, refer to the scoring table in each element or to the file review worksheet in the Interactive Review Tool (IRT).
UM_CR 2019
Yes. For non-file review requirements, if the arrangement was terminated more than 90 calendar days before submission of the completed survey tool, the organization is eligible for automatic credit for the portion of the look-back period when the NCQA-Accredited/ Certified/Recognized delegate conducted activities. For file review requirements, automatic credit is applied if the delegate processed (or handled) the file, regardless of when the delegation arrangement was terminated.
UM_CR 2019
The intent of the added language in factors 2 and 3 was to clarify the minimum information required for expedited appeals. NCQA recognizes these are new requirements, and for this reason, has added the following language to the scope of review:
Organizations must implement the changes in factors 2 and 3 for files processed on or after 11/1/18.
NCQA will post an update in December for the 2019 HP publication to reflect this change.
UM_CR 2019
The first step to earning accreditation is a discussion with an NCQA program expert. Purchase and review the program resources, conduct a gap analysis and submit your online application. Align your organization’s processes with the Provider Network standards. NCQA conducts the survey and determines your accreditation status within 30 days of the final review. |
See a step-by-step process.
UM_CR 2019
Use the NCQA Provider Network Accreditation standards to perform a gap analysis and determine improvement areas. The standards provide a framework for implementing industry best practices to:
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UM_CR 2019
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UM_CR 2019
If you are not currently accredited and want to learn more, contact NCQA. If you are currently accredited and want to talk to someone about your status or about renewing or adding accreditations, submit a question through My NCQA.
UM_CR 2019
Utilization Management Accreditation is for organizations that provide full scope utilization management services. Eligible organizations:
Note: “Members” refers to membership of clients and organizations. |
UM_CR 2019
Find the Standards and Guidelines document in the NCQA eStore.
UM_CR 2019