URAC & NCQA Requirements for Personnel Performing Utilization Reviews

Health Plan Accreditation Guide, Version 7.3

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Table of Contents Copyright: Health Plan

4

Message from URAC

5

MEASURES: Health Plan (HP) and Health Insurance Marketplace (HIM) Memo

6

Florida Addendum for Health Plan Accreditation

7

Introduction to URAC Accreditation Guides and Standards

10

Scoring Methodology

13

Glossary: Health Accreditation Guides and Standards

19

Crosswalk between Core V2.1 & V3.0

42

Crosswalk: Health Plan (v. 7.2 to 7.3) and Health Plan with Health Insurance Marketplace (v 7.2 to 7.3)

43

Applicability of Core Organizational Quality Standards, Version 3.0

45

Medical Loss Ratio (MLR) & URAC Accreditation Fees

46

MLR Table: CORE, Version 3.0

51

MLR Table: Health Plan, Version 7.3

55

CORE, Version 3.0

67

Organizational Structure

67

Policies and Procedures

71

Regulatory Compliance

75

Inter-Departmental Coordination

78

Oversight of Delegated Functions

80

Marketing and Sales Communications

90

Business Relationships

92

Information Management

96

Quality Management

109

Staff Qualifications

129

Staff Management

133

Clinical Staff Credentialing and Oversight Role

140

Health Care System Coordination

154

Consumer Protection and Empowerment

156

Health Plan, Version 7.3

164

Network Management

164

Credentialing

206

Member Relations

247

Quality Management

272

Health Plan Operations

294

Compliance Program

318

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Mental Health Parity

320

Health Utilization Management

326

Measures Reporting

421

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Glossary for Health Accreditation Standards Health benefit plan: A policy, contract, certificate or agreement offered or issued by a health issuer to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

Source: 2008 NAIC Health Carrier Uniform External Review Model Act Health content: Health information that is intended to provide general, user non-specific information or advice about maintaining health or the treatment of an acute or chronic illness, health condition, or disease state.

Health Content Reviewer: An individual who holds a license or certificate as required by the appropriate jurisdiction in a health care field (where applicable), has professional experience in providing relevant direct patient care or has completed formal training in a health-related field.

Health Education: Educational resources designed to enhance the knowledge and understanding of health topics to promote wellness and self-care.

Health Information: Educational resources designed to enhance the knowledge and understanding of health topics to promote wellness and self-care.

Health Information Exchange: The electronic movement of health-related information among organizations according to nationally recognized standards.

Health Information Organization: An organization that oversees and governs the exchange of healthrelated information among organizations according to nationally recognized standards.

Health Information Technology: The technology to create, transmit, store and manage individuals’ health data.

URAC Clinically Integrated Networks Advisory Committee, 2012 Health Literacy: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate decisions regarding their health.

Health Professional: An individual who: (1) has undergone formal training in a health care field; (2) holds an associate or higher degree in a health care field, or holds a state license or state certificate in a health care field; and (3) has professional experience in providing direct patient care.

Health-Related Field: A professional discipline that promotes the physical, psychosocial, or vocational well-being of individual persons.

Health Risk Assessment Process: A process of collecting and interpreting health data and risk factors, gathered from the health risk assessment tool and other sources about the target population, to evaluate potential participants for inclusion in the wellness program.  Note: The term “health risk assessment” and its corresponding acronym “HRA” are not the only terms that define an acceptable assessment process.

URAC Health Accreditations Glossary 2/21/2012 Health Risk Assessment Tool (HRAT): A health risk assessment tool is a systematic approach to collecting information from individuals that identifies risk factors, which can be determined through biometric and other methods, and provides individualized feedback, such as through a health risk score, to increase overall awareness of risk. Definition adopted from the Centers for Medicare and Medicaid Services – CMS).

Healthy Behavior A specific action, taken at the individual level, associated with improved health outcomes and the reduction of risk factors. Healthy behavior may include: • Seeking appropriate health care or tests (e.g., getting a cholesterol screening) • • Avoiding risky behavior (e.g., quitting smoking) • • Engaging in lifestyle changes (e.g., getting more exercise)

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Glossary for Health Accreditation Standards Individually Identifiable Information: Any information that can be tied to an individual consumer, as defined by applicable laws.

Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and: (1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and (i) That identifies the individual; or (ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual. (65 Fed. Reg. at 82,804 (to be codified at 45 C.F.R. pt. 164.501))  Note: This definition is derived from the federal Health Insurance Portability and Accountability Act (HIPAA).

Independent Review: A process, independent of all affected parties, to determine if a health care service is medically necessary and medically appropriate, experimental/investigational or to address administrative/legal issues. Independent review typically (but not always) occurs after all appeal mechanisms available within the health benefits plan have been exhausted. Independent review can be voluntary or mandated by law.

Independent Reviewer: See definition for “Reviewer.”

Information System: Any written, electronic, or graphical method of communicating information. The basis of an information system is the sharing and processing of information and ideas. Computers and telecommunication technologies have become essential information system components.

Barron’s Business Dictionary Initial Clinical Review: Clinical review conducted by appropriate licensed or certified health professionals. Initial clinical review staff may approve requests for admissions, procedures, and services that meet clinical review criteria, but must refer requests that do not meet clinical review criteria to peer clinical review for certification or non-certification. Sometimes referred to as “first level review.”

Initial Screening (formerly “pre-review screening” and “scripted clinical screening”): Automated or semi-automated screening of requests for authorization that may include: (1) collection of structured clinical data (including diagnosis, diagnosis codes, procedures, procedure codes); (2) asking scripted clinical questions; (3) accepting responses to scripted clinical questions; and (4) taking specific action (certification and assignment of length of stay explicitly linked to each of the possible responses). It excludes: (1) applying clinical judgment or interpretation; (2) accepting unstructured clinical information; (3) deviating from script; (4) engaging in unscripted clinical dialogue; (5) asking clinical follow-up questions; (6) issuing non-certifications; and (7) verification of insurance coverage or eligibility.

Inreach: use of consumer interactions inside the primary care / medical home setting to discover gaps in care and identify opportunities for and act on consumer targeted interventions promoting preventive care Adapted from Yabroff KR, et al.

J Am Med Womens Assoc. 2001 Fall;56(4):166-73, 188.

Internal review: Review, including appeal review, by an insurance issuer or group health plan or their designee (i.e., such as a TPA) of an adverse benefit determination.

Source: Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes under the Patient Protection and Affordable Care Act; Interim Final Rule [HHS 45 CFR Part 147] Interoperability: Ability of two or more systems or components to exchange information and to use the information that has been exchanged.

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P-HUM 10 - Initial Clinical Reviewer Qualifications Individuals who conduct initial clinical review possess an active, professional license or certification: (No Weight) (a) To practice as a health professional in a state or territory of the United States; and (Mandatory) (b) With a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review. (Mandatory) Interpretive Information/Commentary ●

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It is URAC’s policy that initial clinical reviewers must hold a U.S. license or certification; however, unlike peer reviewers conducting peer clinical review and appeals, initial clinical reviewers can be located outside of the United States or its territories when performing initial clinical review. Please see standards P-HUM 14 and P-HUM 35, which address peer reviewer qualifications.

Initial clinical reviewers may assist in the notification process for non-certifications.

For drug utilization management review, adequately trained pharmacy technicians are acceptable for conducting initial clinical review provided they work under the supervision of a pharmacist or are acting within the scope of algorithms.

Please reference standard P-HUM 15(a)(i)-(ii) for more information.

Pharmacy technicians are individuals who are either certified/ licensed or who have been adequately trained. “Adequately trained” means that the individual has been part of an extensive training program and/or has had significant experience at a dispensing site.

If pharmacy technicians are conducting reviews, they must be certified/ licensed in accordance with the state where they are practicing if the state requires it.

Adequately trained pharmacy technicians are acceptable for conducting a review provided they work under the supervision of a pharmacist or are acting withing the scope of algorithms.

For non-automated review, pharmacy technicians may not issue clinical non-certifications. ❍ ❍

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Points to Remember ●

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P-HUM 10(a): Clinical review staff must have an active license when performing review activities; organizations must implement a mechanism for tracking licensure expiration dates.

P-HUM 10(a): Review the scope of the nurse practice act and/or licensure requirements for clinical reviewers for all states in which the organization may provide UM services.

P-HUM 10(a): An LPN/LVN meets the URAC definition of health professional and this licensure category may conduct initial clinical review.

HUM 10(a): A certified genetic counselor meets the definition of health professional and individual practitioners with this certification can conduct initial clinical review. Certified genetic counselors may also conduct peer clinical review; for more information, see the supporting guide language for standard HUM 14.

P-HUM 10(b): Initial clinical reviewers must have the appropriate clinical background in order to render decisions requiring clinical judgment and experience.

"Health professionals" is a defined term; please refer to the glossary.

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For information pertaining to mutual recognition model of nurse licensure and the status of legislation for Nurse Licensure Compact for your state, refer to the National Council State Board of Nursing web site at www.NCSBN.org.

Scope of Standards ●

P-HUM 10 through P-HUM 12 cover the initial clinical review staff and processes.

Evidence for Meeting the Standard - Desktop Review Materials ●

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Job description for initial clinical reviewers that includes requirements for licensure and professional education and experience.

Written policies and/or documented procedures describing who conducts initial clinical review.

Evidence for Meeting the Standard - Onsite Review Materials and Activities ●

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Clinical case records illustrating initiation of the review process, pre-review screening, and initial clinical review, concurrent review and retrospective review.

Review of personnel files to include clinical staff credentialing.

Record of primary source verification of licensure for all clinical reviewers.

Bright Ideas ●

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In order to avoid changes in licensure status (e.g., restrictions or revocations) occurring without the company’s knowledge, develop a policy to require licensed personnel to notify their supervisor immediately of any changes in licensure status. Review this policy at the time of hire and annually when conducting the performance appraisal.

Ongoing monitoring of staff licensure through licensure board websites will alert the organization to changes in credentialing status. Electronically track using an ‘alert’ function when staff licensure or certification is due for renewal will assure timely notification of renewal requirements.

To assure timely notification of renewal requirements, develop a credentialing database that includes the licensure review date and expiration date for each clinical staff member for all states where licensed; assign an individual(s) to monitor this data base on a monthly basis.

Develop an attestation statement regarding licensure status. Have the individual review and sign the attestation annually at the time the performance appraisal is conducted.

Related Standards

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Utilization Management

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UM Standards and Elements

Standards for Utilization Management UM 1: Utilization Program Structure Element A: Written Program Description ........................................................................................ 259 Element B: Physician Involvement ................................................................................................. 263 Element C: Behavioral Healthcare Practitioner Involvement ........................................................... 264 Element D: Annual Evaluation ....................................................................................................... 265 UM 2: Clinical Criteria for UM Decisions Element A: UM Criteria .................................................................................................................. 266 Element B: Availability of Criteria ................................................................................................... 269 Element C: Consistency in Applying Criteria .................................................................................. 270 UM 3: Communication Services Element A: Access to Staff ............................................................................................................ 271 UM 4: Appropriate Professionals Element A: Licensed Health Professionals ..................................................................................... 273 Element B: Use of Practitioners for UM Decisions .......................................................................... 274 Element C: Practitioner Review of Nonbehavioral Healthcare Denials ............................................ 276 Element D: Practitioner Review of Behavioral Healthcare Denials .................................................. 277 Element E: Practitioner Review of Pharmacy Denials..................................................................... 278 Element F: Use of Board-Certified Consultants .............................................................................. 280 Element G: Affirmative Statement About Incentives ....................................................................... 281 UM 5: Timeliness of UM Decisions Element A: Timeliness of UM Decision Making .............................................................................. 284 Element B: Notification of Nonbehavioral Decisions ....................................................................... 288 Element C: Timeliness of Behavioral Healthcare UM Decision Making ........................................... 290 Element D: Notification of Behavioral Healthcare Decisions ........................................................... 294 Element E: Timeliness of Pharmacy UM Decision Making .............................................................. 296 Element F: Notification of Pharmacy Decisions .............................................................................. 300 Element G: UM Timeliness Report ................................................................................................. 303 Element H: Interim—Policies and Procedures ................................................................................ 304 UM 6: Clinical Information Element A: Relevant Information for Nonbehavioral Healthcare Decisions ..................................... 308 Element B: Relevant Information for Behavioral Healthcare Decisions ........................................... 309 Element C: Relevant Information for Pharmacy Decisions.............................................................. 311 UM 7: Denial Notices Element A: Discussing a Denial With a Reviewer ........................................................................... 312 Element B: Written Notification of Nonbehavioral Healthcare Denials ............................................. 314 Element C: Nonbehavioral Healthcare Notice of Appeal Rights/Process ........................................ 317 Element D: Discussing a Behavioral Healthcare Denial With a Reviewer ....................................... 319 Element E: Written Notification of Behavioral Healthcare Denials ................................................... 320 Element F: Behavioral Healthcare Notice of Appeal Rights/Process ............................................... 323 Element G: Discussing a Pharmacy Denial With a Reviewer .......................................................... 325 Element H: Written Notification of Pharmacy Denials ..................................................................... 327 Element I: Pharmacy Notice of Appeals Rights/Process ................................................................. 329 UM 8: Policies for Appeals Element A: Internal Appeals .......................................................................................................... 332 Element B: Notice of External Review Rights ................................................................................. 337

2019 HP Standards and Guidelines

Effective for Surveys Beginning On or After July 1, 2019

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UM Standards and Elements

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UM 9: Appropriate Handling of Appeal Element A: Preservice and Postservice Appeals ............................................................................ 339 Element B: Timeliness of the Appeal Process ................................................................................ 341 Element C: Appeal Reviewers ....................................................................................................... 343 Element D: Notification of Appeal Decision/Rights ......................................................................... 344 Element E: Final Internal and External Appeal Files ....................................................................... 347 Element F: Appeals Overturned by the IRO ................................................................................... 348 UM 10: Evaluation of New Technology Element A: Written Process ........................................................................................................... 349 Element B: Description of the Evaluation Process .......................................................................... 350 UM 11: Procedures for Pharmaceutical Management Element A: Pharmaceutical Management Procedures.................................................................... 352 Element B: Pharmaceutical Restrictions/Preferences ..................................................................... 354 Element C: Pharmaceutical Patient Safety Issues .......................................................................... 356 Element D: Reviewing and Updating Procedures ........................................................................... 357 Element E: Considering Exceptions ............................................................................................... 358 UM 12: Delegation of UM Element A: Delegation Agreement ................................................................................................. 361 Element B: Predelegation Evaluation ............................................................................................. 363 Element C: Review of UM Program ............................................................................................... 365 Element D: Opportunities for Improvement .................................................................................... 367

Effective for Surveys Beginning On or After July 1, 2019

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2019 HP Standards and Guidelines

UM 4: Appropriate Professionals

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UM 4: Appropriate Professionals—Refer to Appendix 1 for points Qualified licensed health professionals assess the clinical information used to support UM decisions.

Intent UM decisions are made by qualified health professionals.

Summary of Changes Clarifications • Removed the exception for automatic approval of all services (Elements A–G).

Element A: Licensed Health Professionals—Refer to Appendix 1 for points The organization has written procedures: 1. Requiring appropriately licensed professionals to supervise all medical necessity decisions.

2. Specifying the type of personnel responsible for each level of UM decision making.

Scoring

100% The organization meets 2 factors

80% No scoring option

50% The organization meets 1 factor

20% No scoring option

0% The organization meet 0 factors

Data source

Documented process

Scope of review

This element applies to Interim Surveys, First Surveys and Renewal Surveys.

Look-back period

For Interim Surveys: Prior to the survey date.

For First Surveys: 6 months.

For Renewal Surveys: 24 months.

Explanation

This element is a structural requirement. The organization must present its own documentation.

NCQA reviews the organization’s policies and procedures.

Factor 1: Supervision The policies and procedures specify that the organization uses licensed health care professionals to supervise UM activities. Licensed health care professionals who supervise: • Provide day-to-day supervision of assigned UM staff.

• Participate in staff training.

• Monitor for consistent application of UM criteria by UM staff, for each level and type of UM decision.

• Monitor documentation for adequacy.

• Are available to UM staff on site or by telephone.

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UM 4: Appropriate Professionals

Factor 2: UM personnel and appropriate professionals The policies and procedures specify that the organization uses licensed health care professionals to make UM decisions that require clinical judgment. The following staff may approve services: • Staff who are not qualified health care professionals and are under the supervision of appropriately licensed health professionals, when there are explicit UM criteria and no clinical judgment is required.

• Licensed health care professionals.

Exceptions None.

Related information UM oversight. As specified in UM 1, Element A, a senior-level physician oversees the UM program and a designated behavioral healthcare practitioner is involved in the behavioral health aspects of the UM program. These individuals are not required to have day-to-day involvement in UM activities.

For doctoral-level clinical psychologists, such authority must be in the scope of their license to practice.

Examples

None.

Element B: Use of Practitioners for UM Decisions—Refer to Appendix 1 for points The organization has a written job description with qualifications for practitioners who review denials of care based on medical necessity. Practitioners are required to have: 1. Education, training or professional experience in medical or clinical practice.

2. A current clinical license to practice or an administrative license to review UM cases.

Scoring

100% The description includes 2 factors for all appropriate practitioners

80% No scoring option

50% The description includes 1 factor for all appropriate practitioners

20% The description includes 1-2 factors for some appropriate practitioners

0% The description meets 0 factors

Data source

Materials

Scope of review

This element applies to Interim Surveys, First Surveys and Renewal Surveys.

Look-back period

For Interim Surveys: Prior to the survey date.

For First Surveys: 6 months.

For Renewal Surveys: 24 months.

NCQA reviews the organization’s practitioner job descriptions in place during the look-back period.

2019 HP Standards and Guidelines

Effective for Surveys Beginning On or After July 1, 2019

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UM 4: Appropriate Professionals

Explanation

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This element is a structural requirement. The organization must present its own materials.

The written description applies to all types of practitioners who may review denials of care based on medical necessity for the organization. NCQA considers the following practitioner types to be appropriate for review of the specified UM denial decisions: • Physicians, all types: Medical, behavioral healthcare, pharmaceutical, dental, chiropractic and vision denials.

• Nurse practitioners*: Medical, behavioral healthcare, pharmaceutical, dental, chiropractic and vision denials.

• Doctoral-level clinical psychologists or certified addiction-medicine specialists: Behavioral healthcare denials.

• Pharmacists: Pharmaceutical denials.

• Dentists: Dental denials.

• Chiropractors: Chiropractic denials.

• Physical therapists: Physical therapy denials. * In states where the organization has determined that practice acts, or regulations allow nurse practitioners may practice as independent practitioners, nurse practitioners may review requests that are within the scope of their license.

Factor 1: Education, training or professional experience No additional explanation required.

Factor 2: Current clinical or administrative license An administrative license is a limited license that allows practitioners to use clinical skills and knowledge to make judgment on the medical or clinical appropriateness of requested care or services but does not convey the authority to practice clinical medicine or to prescribe medications.

Exceptions None.

Examples

None.

Effective for Surveys Beginning On or After July 1, 2019

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UM 4: Appropriate Professionals

Element C: Practitioner Review of Nonbehavioral Healthcare Denials —Refer to Appendix 1 for points The organization uses a physician or other health care professional, as appropriate, to review any nonbehavioral healthcare denial based on medical necessity.

Scoring

100% High (90100%) on file review

80% No scoring option

50% Medium (6089%) on file review

20% No scoring option

Data source

Records or files

Scope of review

This element applies to First Surveys and Renewal Surveys.

Look-back period

For First Surveys: 6 months.

For Renewal Surveys: 12 months.

Explanation

THIS IS A MUST-PASS ELEMENT.

0% Low (0-59%) on file review

NCQA reviews a random sample of up to 40 nonbehavioral healthcare denial files resulting from medical necessity review (as defined in UM 1, Element A) for evidence that the files were reviewed by an appropriate practitioner.

This element applies to all nonbehavioral healthcare denial determinations resulting from medical necessity review (as defined in UM1, Element A).

Dispute of file review results NCQA conducts onsite file review in the presence of the organization’s staff and works with the organization to resolve any disputes during the onsite survey. An organization that is unable to resolve a dispute with the survey team must contact NCQA before the onsite survey is complete. File review results may not be disputed, and may not be appealed once the onsite survey is complete.

Appropriate practitioner review Appropriate practitioners review all medical necessity denials for requested health care services offered under the organization’s medical benefit. NCQA does not require practitioner review of requests for medical services that are specifically excluded from the benefits plan or that exceed the limitations or restrictions stated in the benefits plan.

The UM denial file includes any of the following documentation of appropriate professional review: • The reviewer’s handwritten signature or initials.

• The reviewer’s unique electronic signature or identifier on the denial letter or on the notation of denial in the file.

• A signed or initialed note from a UM staff person, attributing the denial decision to the professional who reviewed and decided the case.

Exceptions None.

2019 HP Standards and Guidelines

Effective for Surveys Beginning On or After July 1, 2019

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UM 4: Appropriate Professionals

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Related information Refer to UM 1, Element A for the definition of “medical necessity review.”

UM denial file exclusions. NCQA does not include UM decisions that do not require medical necessity review within the UM denial file sample.

Dental benefits. If medical and dental benefits are not differentiated in the benefits plan, the organization identifies dental care or services associated with procedures that occur within or adjacent to the oral cavity or sinuses. NCQA requires medical necessity review of requests for these services.

Examples

None.

Element D: Practitioner Review of Behavioral Healthcare Denials —Refer to Appendix 1 for points The organization uses a physician or appropriate behavioral healthcare practitioner, as appropriate, to review any behavioral healthcare denial of care based on medical necessity.

Scoring

100% High (90100%) on file review

80% No scoring option

50% Medium (6089%) on file review

20% No scoring option

Data source

Records or files

Scope of review

This element applies to First Surveys and Renewal Surveys.

Look-back period

For First Surveys: 6 months.

For Renewal Surveys: 12 months.

Explanation

THIS IS A MUST-PASS ELEMENT

0% Low (0-59%) on file review

NCQA reviews a random sample of up to 40 behavioral healthcare denial files resulting from medical necessity review (as defined in UM 1, Element A) for evidence that the files were reviewed by an appropriate practitioner.

This element applies to all behavioral healthcare denial determinations resulting from medical necessity review (as defined in UM1, Element A).

Dispute of file review results NCQA conducts onsite file review in the presence of the organization’s staff and works with the organization to resolve any disputes during the onsite survey. An organization that is unable to resolve a dispute with the survey team must contact NCQA before the onsite survey is complete. File review results may not be disputed, and may not be appealed once the onsite survey is complete.

Appropriate practitioner review Appropriate practitioners review all medical necessity denials for requested health care services offered under the organization’s behavioral healthcare benefit.

NCQA does not require practitioner review of requests for medical services that are specifically excluded from the benefits plan or that exceed the limitations or restrictions stated in the benefits plan.

Effective for Surveys Beginning On or After July 1, 2019

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UM 4: Appropriate Professionals

The UM denial file includes any of the following documentation of appropriate professional review: • The reviewer’s handwritten signature or initials.

• The reviewer’s unique electronic signature or identifier on the denial letter or on the notation of denial in the file.

• A signed or initialed note from a UM staff person, attributing the denial decision to the professional who reviewed and decided the case.

Exception This element is NA if all purchasers of the organization’s services carve out or exclude behavioral healthcare.

Related information Refer to UM 1, Element A for the definition of “medical necessity review.”

UM denial file exclusions. NCQA does not include UM decisions within the UM denial file sample that do not require medical necessity review.

Examples

None.

Element E: Practitioner Review of Pharmacy Denials—Refer to Appendix 1 for points The organization uses a physician or a pharmacist to review pharmacy denials based on medical necessity.

Scoring

100% High (90100%) on file review

80% No scoring option

50% Medium (6089%) on file review

20% No scoring option

Data source

Records or files

Scope of review

This element applies to First Surveys and Renewal Surveys.

Look-back period

For First Surveys: 6 months.

For Renewal Surveys: 12 months.

Explanation

THIS IS A MUST-PASS ELEMENT.

0% Low (0-59%) on file review

NCQA reviews a random sample of up to 40 pharmaceutical denial files resulting from medical necessity review (as defined in UM 1, Element A) for evidence that the files were reviewed by an appropriate practitioner.

This element applies to all pharmaceutical denial determinations resulting from medical necessity review (as defined in UM1, Element A).

Dispute of file review results NCQA conducts onsite file review in the presence of the organization’s staff and works with the organization to resolve any disputes during the onsite survey. An organization that is unable to resolve a dispute with the survey team must contact NCQA before the onsite survey is complete. File review results may not be disputed, and may not be appealed once the onsite survey is complete.

2019 HP Standards and Guidelines

Effective for Surveys Beginning On or After July 1, 2019

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Appropriate practitioner review Appropriate practitioners review all medical necessity denials for requested pharmaceuticals offered under the organization’s pharmacy benefit. NCQA does not require practitioner review of requests for medical services that are specifically excluded from the benefits plan or that exceed the limitations or restrictions stated in the benefits plan.

The UM denial file includes any of the following as documentation of appropriate professional review: • The reviewer’s handwritten signature or initials.

• The reviewer’s unique electronic signature or identifier on the denial letter or on the notation of denial in the file.

• A signed or initialed note from UM staff, attributing the denial decision to the professional who reviewed and decided the case. The reviewer’s handwritten signature or initials.

Exception This element is NA if all purchasers of the organization’s services carve out or exclude pharmaceutical management.

Related information Refer to UM 1, Element A for the definition of “medical necessity review.”

UM denial file exclusions. NCQA does not include the following UM decisions in the UM denial file sample: • UM decisions that do not require medical necessity review.

• UM approvals, including substitution of a generic pharmaceutical for a name-brand pharmaceutical.

• Pharmacy benefit denials resulting from closed formularies and related to tiered formularies, copayments, generic substitution and therapeutic interchange.

Examples

None.

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UM 4: Appropriate Professionals

Element F: Use of Board-Certified Consultants—Refer to Appendix 1 for points The organization: 1. Has written procedures for using board-certified consultants to assist in making medical necessity determinations.

2. Provides evidence that it uses board-certified consultants for medical necessity determinations.

Scoring

100% There is evidence of the organization’s written procedures and practice of using boardcertified consultants

80% No scoring option

50% There is evidence that the organization uses boardcertified consultants but does not have written procedures

20% No scoring option

0% The organization does not have written procedures and there is no evidence that it uses boardcertified consultants

Data source

Documented process, Reports, Records or files

Scope of review

This element applies to Interim Surveys, First Surveys and Renewal Surveys.

NCQA reviews the organization’s procedures for using board-certified consultants and reviews the list of consultants.

For First Surveys and Renewal Surveys: NCQA also reviews at least three cases showing the use of consultants during the look-back period.

Look-back period

For Interim Surveys: Prior to the survey date.

For First Surveys: 6 months.

For Renewal Surveys: 24 months.

Explanation

This element applies to medical necessity determinations.

Factor 1: Procedures for using board-certified consultants The organization has written procedures for using board-certified consultants, that include a policy that defines the use of board-certified consultants and a list of board-certified consultants.

Factor 2: Evidence of use of board-certified consultants No additional explanation required.

Exception Factor 2 is NA if the organization does not use board-certified consultants for medical necessity determinations because all specialties are available within the organization to assist with UM determinations.

Related information NCQA does not consider it delegation when a board-certified consultant reviews cases for medical necessity determinations.

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UM 4: Appropriate Professionals

Examples

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Factors 1, 2: Use of board-certified consultant An attending physician believes a newborn is suffering from a neurological disorder. The physician requests approval for the infant to be treated by a pediatric neurologist. The organization does not have a pediatric neurologist on staff or in its network, but it does have access to a board-certified pediatric neurologist through a consulting firm. The organization collects the necessary clinical information and sends it to the consulting neurologist, who replies with a recommendation for authorization to an out-of-network pediatric neurologist within 24 hours.

Element G: Affirmative Statement About Incentives—Refer to Appendix 1 for points The organization distributes a statement to all members and to all practitioners, providers and employees who make UM decisions, affirming the following: 1. UM decision making is based only on appropriateness of care and service and existence of coverage.

2. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.

3. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

Scoring

100% The organization distributed a statement with all 3 factors to all 4 groups

80% The organization distributed a statement with all 3 factors to 3 groups, including practitioners and members

50% The organization distributed a statement with all 3 factors to 2 groups; or the organization distributed a statement with 2 factors to 3 groups, including practitioners and members

20% The organization distributed a statement with all 3 factors to 1 group; or the organization distributed a statement with 1-2 factors to 1-2 groups

0% The organization has not distributed a statement

Data source

Reports, Materials

Scope of review

This element applies to Interim Surveys, First Surveys and Renewal Surveys.

NCQA reviews the organization’s affirmative statement against the required factors.

For First Surveys and Renewal Surveys: NCQA also reviews the organization’s communication of the affirmative statement to each member and each practitioner, provider and employee who makes UM decisions at least once during the lookback period.

Look-back period

For Interim Surveys: Prior to the survey date.

For First Surveys and Renewal Surveys: 24 months.

Effective for Surveys Beginning On or After July 1, 2019

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2019 HP Standards and Guidelines

282

UM 4: Appropriate Professionals

Explanation

The organization’s affirmative statement declares that the organization does not use incentives to encourage barriers to care and service. This element does not preclude the use of appropriate incentives for fostering efficient, appropriate care.

Distributing affirmative statement about incentives The organization distributes its affirmative statement about incentives by mail, fax or email, or on its website, if it informs members, practitioners, providers and employees that the information is available on line. The organization mails its affirmative statement about incentives to recipients who do not have fax, email or internet access.

Factors 1–3 No additional explanation required.

Exceptions None.

Examples

None.

2019 HP Standards and Guidelines

Effective for Surveys Beginning On or After July 1, 2019

Page 20