FAQ Directory: Utilization Management, Credentialing and Provider Network

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10.15.2016 Scoring organizations 100% for UM 4, Element H How are organizations scored for UM 4, Element H (UM 4, Element F in MBHO and UM-CR) under the 2016 Standards and Guidelines?

For the 2016 standards year, NCQA evaluates and scores the UM 4, Element H file review as normal during the onsite survey.
The final score will be adjusted, after the onsite survey, to 100% if the organization includes all denials required by UM 4, Element H in the file review universe. 
If the organization does not include all denials in the file review universe, NCQA will adjust the organization's final score to 50% for the 2016 standards year and 0% thereafter.
 

UM_CR 2016