FAQ Directory: Utilization Management, Credentialing and Provider Network

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9.15.2018 Revised Look-back Period for UM 7, Elements C, F, I (factors 2 and 3) In the 2019 HPA Standards and Guidelines, NCQA added a fifth bullet to the factor 2 Explanation and revised the factor 3 Explanation in UM 7, Elements C, F and I. Will NCQA give organizations a grace period for the added information in factors 2 and 3 of UM 7, Elements C, F and I?

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