On or After July 1, 2016
Standards and Guidelines
for the Accreditation of Managed Behavioral Healthcare Organizations
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Item #10550-100-16
Acknowledgments
Acknowledgments
NCQA is pleased to release the 2016 Standards and Guidelines for the Accreditation of MBHOs, effective for surveys beginning on or after July 1, 2016. The Standards and Guidelines are available in both the Web-based Interactive Survey System (ISS) and e-pub format.
Updating this year’s Standards and Guidelines would not have been possible without a team effort by the staff of NCQA’s Accreditation and Recognition Operations, Product Design and Support and Information Systems Departments.
The NCQA Standards Committee, Review Oversight Committee, Accreditation and Certification Users Group and surveyors also provided invaluable insight to help enhance NCQA’s MBHO Accreditation Program. In addition, NCQA received important input from health plans, purchasers, consumers, policymakers and others who offered suggestions on proposed changes to the Standards and during the Public Comment period.
Sincerely,
Margaret E. O’Kane
President, NCQA
Effective for Surveys Beginning On or After July 1, 2016 2016 MBHO Standards and Guidelines
Acknowledgments
Standards Committee
John Fallon, MD, MBA (Chair)Blue Cross Blue Shield of Massachusetts
Andy Baskin, MD
Aetna
Barbara Caress
Independent Consultant
Sabrina Corlette, JD
Georgetown University Health Policy Institute
Chris Dennis, MD, MBA, FAPA
Landmark Health
Elizabeth Goldstein, PhD
Centers for Medicare & Medicaid Services
Kathleen Harris, MPH
Time Warner, Inc.
Alice Lind, RN, MPH
Washington State Healthcare Authority
Wendy Long, MD, MPH
Health Care Finance and Administration
(State of Tennessee)
Kevin McCabe, MD
SC Johnson & Son, Inc.
Anne Mutti
Mathematica Policy Research / Gordon Norman, MD
Towers Watson
Kirsten Sloan
American Cancer Society, Cancer Action Network, Inc.
Ilene Stein
SEIU
Susan Stuard, MBA
Lakefleet Consulting
Liaisons
Victor Caraballo, MD, MBA
Independence Blue Cross
Kirstin Dawson, MS
America’s Health Insurance Plans
Carole Redding Flamm, MD, MPH
BlueCross BlueShield Association
Pamela Greenberg, MPP
Association for Behavioral Health and Wellness
Deborah Kilstein, MBA, RN
Association for Community Affiliated Plans
Effective for Surveys Beginning On or After July 1, 2016 2016 MBHO Standards and Guidelines
Table of Contents
Table of Contents
Overview
Notable Changes for 2016 1
Accreditation: A Symbol of Quality and Improvement 1
Why NCQA? 1
The Value of MBHO Accreditation 1
Organizations With MBHO Accreditation Help Health Plans in the Accreditation Process 2
Accreditation Status Levels 2
Where to Find Specific Information 3
Other Important NCQA Information 4
Other NCQA Programs 5
Policies and Procedures
Section 1: Eligibility and the Application Process
Eligibility for Accreditation 9
Right to Decline to Survey 9
How NCQA Defines an Accreditable Entity 9
Applying for an NCQA Survey 10
Organization Obligations 11
Section 2: The Accreditation Process
Accreditation Survey Types 12
Full Survey 12
Resurvey 12
Introductory Survey 13
Add-On Survey 13
Corporate Survey 14
Expedited Survey 15
State and Federal Agency Survey 15
Accreditation Status 16
How Standards Are Scored 17
A Standard’s Structure 17
Scoring Guidelines 20
Must-Pass Elements 20
Core Standards 21
Other Information NCQA May Consider 21
Notification to Regulatory Agencies 21
Disclaimer 21
Section 3: The Survey Process
About the Survey Process 22
Survey Results and Scoring 24
Reconsideration 25
Subsequent Accreditation Survey 26
Section 4: Reporting Results
Releasing Information 27
Reporting Accreditation Status to the Public 28
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35
Section 5: Additional Information
Complaint Review Process 29
Reporting Hotline for Fraud and Misconduct 29
Discretionary Survey 30
Suspending Accreditation 30
Revoking Accreditation 31
Mergers and Acquisitions 31
Lapse in Accreditation Status 31
Privacy, Security and Confidentiality Requirements 32
Revisions to Policies and Procedures 32
Standards for Quality Management and Improvement
QI 1: Program Structure
Element A: Quality Improvement Program Structure 37
Element B: Annual Evaluation 40
QI 2: Program Operations
Element A: QI Committee Responsibilities 42
Element B: Informing Practitioners and Members 44
Element C: Sharing Evaluation Results 45
QI 3: Health Services Contracting
Element A: Practitioner Contracts 46
Element B: Affirmative Statement 47
Element C: Provider Contracts 48
QI 4: Availability of Practitioners and Providers
Element A: Cultural Needs and Preferences 50
Element B: Ensuring Availability 52
QI 5: Accessibility of Services
Element A: Assessment Against Access Standards 55
Element B: Assessment Against Telephone Standards 57
QI 6: Member Experience
Element A: Annual Assessment 59
Element B: Scope of Survey 61
Element C: Improvement Activities 62
QI 7: Behavioral Health Screening
Element A: Screening Programs 65
Element B: Program Description 66
Element C: Programs Based on Scientific Literature 68
Element D: Distribution of Program Information to Practitioners and Providers 69
QI 8: Self-Management Tools
Element A: Topics of Tools 70
Element B: Usability Testing 72
Element C: Review and Update Process 73
Element D: Formats 74
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Table of Contents
QI 9: Complex Case Management
Element A: Population Assessment 76
Element B: Program Description 78
Element C: Identifying Members for Case Management 80
Element D: Access to Case Management 82
Element E: Case Management Systems 83
Element F: Case Management Process 84
Element G: Initial Assessment 89
Element H: Case Management-Ongoing Management 91
Element I: Member Experience With Case Management 92
Element J: Measuring Effectiveness 94
QI 10: Clinical Practice Guidelines
Element A: Adopting Relevant Guidelines 97
Element B: Performance Measurement 99
QI 11: Clinical Measurement Activities
Element A: Process for Data Collection and Integration 101
Element B: Clinical Quality Improvements 102
Element C: Performance Measures 106
QI 12: Effectiveness of the QI Program
Element A: Meaningful Clinical Improvements 109
Element B: Meaningful Service Improvements 113
QI 13: Delegation of QI
Element A: Delegation Agreement 118
Element B: Provisions for PHI 120
Element C: Predelegation Evaluation 121
Element D: Review of the QI Program 122
Element E: Opportunities for Improvement 123
Standards for Care Coordination
CC 1: Coordination of Behavioral Healthcare
Element A: Data Collection 127
Element B: Opportunities for Coordination 128
Element C: Improving Coordination 129
Element D: Measuring Effectiveness 130
CC 2: Collaboration Between Behavioral Healthcare and Medical Care
Element A: Data Collection 132
Element B: Collaboration Between Behavioral Healthcare and Medical Care 134
Element C: Measuring Effectiveness 136
CC 3: Continued Access to Care
Element A: Notification of Termination 138
Element B: Continued Access to Practitioners 139
Element C: Care Transitions 141
CC 4: Technology to Improve Care Coordination
Element A: Member Support 142
CC 5: Delegation of CC
Element A: Delegation Agreement 144
Element B: Provisions for PHI 146
Element C: Predelegation Evaluation 147
Element D: Review of Delegated Activities 148
Element E: Opportunities for Improvement 149
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Table of Contents
Standards for Utilization Management
UM 1: Utilization Management Structure
Element A: Written Program Description 155
Element B: Behavioral Healthcare Practitioner Involvement 158
Element C: Annual Evaluation 159
UM 2: Clinical Criteria for UM Decisions
Element A: UM Criteria 160
Element B: Availability of Criteria 162
Element C: Consistency in Applying Criteria 163
UM 3: Communication Services
Element A: Access to Staff 165
UM 4: Appropriate Professionals
Element A: Licensed Health Professionals 167
Element B: Use of Practitioners for UM Decisions 168
Element C: Practitioner Review of Denials 169
Element D: Use of Licensed Consultants 171
Element E: Affirmative Statement About Incentives 172
Element F: Appropriate Classification of Denials 173
UM 5: Timeliness of UM Decisions
Element A: Timeliness of UM Decision Making 174
Element B: Notification of Decisions 177
Element C: UM Timeliness Report 179
UM 6: Clinical Information
Element A: Relevant Information 181
UM 7: Denial Notices
Element A: Discussing a Denial With a Reviewer 183
Element B: Written Notification of Denials 184
Element C: Notification of Appeal Rights/Process 186
UM 8: Policies for Appeals
Element A: Internal Appeals 189
Element B: Notice of External Appeal Rights 193
UM 9: Appropriate Handling of Appeals
Element A: Preservice and Postservice Appeals 195
Element B: Timeliness of the Appeal Process 196
Element C: Appeal Reviewers 198
Element D: Notification of Appeal Decision/Rights 199
Element E: Final Internal and External Appeal Files 201
Element F: Appeals Overturned by the IRO 202
UM 10: Experience With the UM Process
Element A: Assessing Experience 203
UM 11: Emergency Services
Element A: Coverage of Emergency Services 205
UM 12: Triage and Referral for Behavioral Healthcare
Element A: Triage and Referral Protocols 207
Element B: Supervision and Oversight 209
UM 13: Functionality of Claims Processing
Element A: Functionality—Web Site 210
Element B: Functionality—Telephone Requests 216
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UM 14: Delegation of UM
Element A: Written Delegation Agreement 214
Element B: Provisions for PHI 216
Element C: Predelegation Evaluation 217
Element D: Review of the UM Program 218
Element E: Opportunities for Improvement 219
Standards for Credentialing and Recredentialing
CR 1: Credentialing Policies
Element A: Practitioner Credentialing Guidelines 223
Element B: Practitioner Rights 228
CR 2: Credentialing Committe
Element A: Credentialing Committee 230
CR 3: Credentialing Verification
Element A: Verification of Credentials 232
Element B: Sanctions 236
Element C: Credentialing Application 238
CR 4: Recredentialing Cycle Length
Element A: Recredentialing Cycle Length 241
CR 5: Practitioner Office Site Quality
Element A: Performance Standards and Thresholds 243
Element B: Site Visits and Ongoing Monitoring 244
CR 6: Ongoing Monitoring
Element A: Ongoing Monitoring and Interventions 246
CR 7: Notification to Authorities and Practitioner Appeal Rights
Element A: Actions Against Practitioners 249
Element B: Reporting to the Appropriate Authorities 251
Element C: Practitioner Appeal Process 252
CR 8: Assessment of Organizational Providers
Element A: Review and Approval of Provider 253
Element B: Behavioral Healthcare Providers 255
Element C: Assessing Behavioral Healthcare Providers 256
CR 9: Delegation of CR
Element A: Delegation Agreement 257
Element B: Provision for PHI 259
Element C: Predelegation Evaluation 260
Element D: Review of the Credentialing Process 261
Element E: Opportunities for Improvement 263
Standards for Members’ Rights and Responsibilities
RR 1: Statement of Members’ Rights and Responsibilities
Element A: Rights and Responsibilities Statement 267
Element B: Distribution of Rights Statement 268
RR 2: Policies for Complaints and Appeals
Element A: Policies and Procedures for Complaints 270
Element B: Policies and Procedures for Appeals 271
RR 3: Subscriber Information
Element A: Subscriber Information 273
Element B: Interpreter Services 275
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Table of Contents
RR 4: Practitioner and Provider Directories
Element A: Practitioner Directory Data 277
Element B: Practitioner Directory Updates 279
Element C: Practitioner Information Validation 279
Element D: Searchable Practitioner Web-Based Directory 280
Element E: Provider Directory Data 281
Element F: Provider Directory Updates 282
Element G: Provider Information Validation 283
Element H: Searchable Provider Web-Based Directory 284
Element I: Usability Testing 285
Element J: Availability of Directories 286
RR 5: Privacy and Confidentiality
Element A: Adopting Written Policies 287
Element B: Physical and Electronic Access 289
Element C: Protection for PHI Sent to Plan Sponsors 290
Element D: Authorization 292
Element E: Communication of PHI Use and Disclosure 292
Element F: Accountability and Responsibility 294
Element G: Chief Privacy Officer/Privacy Committee 295
Element H: Web Site 296
RR 6: Delegation of RR
Element A: Delegation Agreement 297
Element B: Provisions for PHI 299
Element C: Predelegation Evaluation 300
Element D: Review of Performance 301
Element E: Opportunities for Improvement 302
Appendices
Appendix 1: Standard and Element Points for 2016
Appendix 2: Core Standards Required for MBHO Accreditation
Appendix 3: Delegation and Automatic Credit Guidelines
Appendix 4: Merger, Acquisition and Consolidation Policy for MBHOs
Appendix 5: Answers to Commonly Asked Questions
Appendix 6: Glossary
Appendix 7: Summary of Changes for 2016
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Overview 1
Overview
Notable Changes for 2016
· Incorporated text about NCQA’s fraud policy under Reporting Hotline for Fraud and Misconduct.
· Simplified file review scoring language in all file review elements in QI, UM and CR.
· Added a new element about classification of denials to UM 4.
· Added a new element about UM timeliness report to UM 5.
· Eliminated former UM 8 Element B: External Reviews in States Without Laws.
· Combined CR 9 Elements A and C into one element.
Accreditation: A Symbol of Quality and Improvement
Why NCQA?
Managed behavioral healthcare organizations (MBHOs) accredited by NCQA demonstrate to health plans, employers, regulators and consumers that an organization follows industry best practices for providing high-quality care, access and consumer protections. Health plans, employers and regulatory entities often ask their contracted organizations to become accredited.
NCQA is the industry gold standard for evaluating performance of managed care entities, with strong name recognition and innovative, meaningful quality review. NCQA is also recognized outside the managed care industry for its work evaluating aspects of the health care delivery system—for example, patient-centered medical homes (PCMH) and accountable care organizations (ACO). NCQA MBHO Accreditation is a comprehensive review of an organization, not merely a review of one or two elements of a program.