Effective for Surveys Beginning On or After July 1, Standards and Guidelines for Physician and Hospital Quality Certification

Transcription

1 Effective for Surveys Beginning On or After July 1, 2013 Standards and Guidelines for Physician and Hospital Quality Certification

2 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system, without the written permission of NCQA by the National Committee for Quality Assurance th Street NW, Third Floor Washington, DC All rights reserved. Printed in the U.S.A. NCQA Customer Support: NCQA Fax: NCQA Web Site: NCQA Policy Clarification Support via Internet at: Item #

3 Acknowledgments Acknowledgments NCQA is pleased to release the 2013 Standards and Guidelines for Physician and Hospital Quality Certification, effective for surveys beginning on or after July 30, The Standards and Guidelines are available in both the Web-based Interactive Survey System (ISS) and in an electronic publication. The development of the Physician and Hospital Quality Standards and Guidelines would not have been possible without a team effort by the staff of NCQA s Product Development, Product Delivery, Information Systems and Marketing and Communications Departments. The NCQA Standards Committee also provided invaluable insight to help update NCQA s Physician and Hospital Quality program. In addition, NCQA received important input from providers, health plans, purchasers, consumers, policymakers and others who offered suggestions on the standards and measures during the Public Comment period. Sincerely, Margaret E. O Kane President, NCQA For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

4 Acknowledgments Standards Committee John Fallon, MD (Chair) Blue Cross Blue Shield of Massachusetts Barbara Caress Building Service 32BJ Funds Chris Dennis, MD, MBA ValueOptions Sue Felt-Lisk Mathematica Elizabeth Goldstein, PhD Centers for Medicare & Medicaid Services Lisa Latts, MD, MBA WellPoint, Inc. Alice Lind, RN, MPH Center for Health Care Strategies, Inc. Kevin McCabe, MD SC Johnson Gordon Norman, MD Alere Laurel Pickering, MPH Northeast Business Group on Health Susan Stuard, MBA THINC, Inc. Liaisons Duane Davis, MD, FACP, FACR Geisinger Health Plan Kirstin Dawson, MS America s Health Insurance Plans Liza Greenberg, RN, MPH AAPPO Pamela Greenberg, MPP Association of Behavioral Health and Wellness Deborah Kilstein Association for Community Affiliated Plans Matthew Schuller Blue Cross Blue Shield Association Carolyn Pare Buyers Health Care Action Group 2013 PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

5 Table of Contents Table of Contents Overview NCQA s Physician and Hospital Quality Certification... 1 Program Objectives... 1 A Standard s Structure... 2 Summary of Changes... 3 Where to Find Specific Information... 4 Other NCQA Accreditation, Certification, Recognition and Evaluation Programs... 5 Policies and Procedures Section 1: Eligibility and the Application Process Eligibility for Certification... 9 How NCQA Defines an Organization for Certification Right to Decline to Survey Organization Obligations Applying for an NCQA Survey Section 2: The Certification Process Components of Certification Certification Status Interim PQ Certification Adjusting Certification Status Certification Survey Types Reporting Certification Results to the Public Reporting Certification Status to the Public Section 3: The Survey Process About the Survey Process Offsite Survey Onsite Survey Scoring Guidelines Scoring and Certification Status Survey Report and Scoring Disclaimer Section 4: Additional Information Reconsideration Complaint Review Process Reporting Hotline for Fraud and Misconduct Discretionary Survey Program Change Review Suspending Certification Revoking Certification Mergers and Acquisitions Lapse in Certification Status Privacy, Security and Confidentiality Requirements Revisions to Policies and Procedures Physician Quality Standards PQ 1: Measures and Methods PQ 2: Working With Physicians PQ 3: Working With Customers PQ 4: Program Input and Improvement Hospital Quality Standard HQ 1: Hospital Performance For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

6 2013 PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

7 Overview 1 Overview NCQA is pleased to release the 2013 Standards and Guidelines for Physician and Hospital Quality Certification, effective July 30, NCQA s Physician and Hospital Quality Certification Provider-level quality data inform consumers, influence network design and form the basis of pay-forperformance programs across the nation. The physician community wants assurance that this information is accurate. Consumers, employers and other purchasers need valid information to help them find the best providers. Regulators concern is that measurement and reporting are fair to all. Accordingly, it is vital to discern whether provider measurement programs are valid and trustworthy. The NCQA Physician and Hospital Quality (PHQ) standards address critical activities undertaken by health plans and other organizations to measure physician and hospital quality. This update moves evaluation from the organization level to the program level, and allows organizations to choose the programs they bring forward for certification (rather than requiring all measurement activities to be brought forward). Evaluation at the program level reduces burden while maintaining rigor. Program Objectives The PHQ standards define how organizations can report differences among providers in a way that is accurate, fair to providers and useful to consumers and purchasers. The technical complexity of measuring performance of physicians and hospitals remains a challenge for those creating and using programs; in addition, measurement methodologies are rapidly evolving. Customers need to understand how an organization evaluates cost and quality; providers need to understand how an organization uses data on quality and cost. PHQ standards evaluate key elements of eligible programs to certify that measurement results are accurate. To remain current with the health care industry s changing capabilities and priorities, NCQA regularly updates its accreditation and certification requirements. Proposed updates for 2013 highlight opportunities to incorporate industry changes and reduce burden on organizations coming forward for accreditation or certification, without compromising accuracy. The updates contain edits to only the physician quality portion of PHQ. Program Principles The following principles guide NCQA s PHQ Certification program. Standardization and sound methodology. Programs that use standardized measures and implement them correctly accomplish several things: lend the credibility of national, independent experts; allow results to be compared among organizations; facilitate data aggregation; and make data collection less burdensome for physicians. Transparency. For measurement efforts to be credible, both to those who are evaluated and to those who will rely on the results, the process must be entirely transparent. Organizations should offer physicians and hospitals the opportunity to weigh in on measure-and-act programs; to understand how a program affects them (including the tiering process); to have their questions answered; to correct data. Organizations should communicate how they measure and make decisions, so consumers and purchasers can understand what ratings or rankings mean and understand their limitations. For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

8 2 Overview Collaboration. Provider measurement must avoid redundant effort. When organizations pool data on standardized measures, they can produce results with greater statistical reliability. Collaboration can also produce results that physicians trust more than single-organization measures. A Standard s Structure Each standard contains the following information. Standard statement Intent statement Summary of changes Element Factor Scoring Data source States acceptable performance or results. States the goal of the standard. Changes to the standards and guidelines. The Summary of Changes is organized into three categories: 1. Additions New requirements. 2. Deletions Retired requirements. 3. Clarifications Modifications and revisions based on frequently asked questions from customers, surveyors and NCQA staff. The scored component of a standard that provides details about performance expectations. NCQA evaluates each element within a standard to determine how well the organization meets the standard s requirements. A scored item in an element. For example, an element may require the organization to demonstrate that its policies and procedures include four items; each item is a factor. The level of performance the organization must demonstrate to receive a specified percentage of element points. Each element has up to five possible scoring levels (100%, 80%, 50%, 20%, 0%). Types of documentation or evidence that the organization uses to demonstrate performance on an element. NCQA defines four types of data sources. 1. Documented process Policies and procedures, process flow charts, protocols and other mechanisms that describe an actual process used by the organization. 2. Reports Aggregated sources of evidence of action or compliance with an element, including management reports; key indicator reports; summary reports from patient reviews; system output giving information like number of patients providing feedback; minutes; and other documentation of actions that the organization has taken. 3. Materials Prepared information or content that the organization provides to its patients, practitioners and delegates, including written and electronic communication, Web sites, scripts, brochures, reviews and clinical guidelines; contracts or agreements with delegates and vendors. 4. Records or files Actual credentialing files or patient records that show direct evidence of action or compliance with an element PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

9 Overview 3 The organization must submit evidence to NCQA when it submits the Survey Tool or during the onsite survey, as specified. Although an element may list multiple data sources, the organization can meet the requirement with one data source, or with any combination of data sources, unless otherwise specified in the explanation. Scope of review Look-back period Explanation Example The extent of the organization s services evaluated during an NCQA Survey. The scope of review depends on the elements evaluated. The time period for which the organization must demonstrate performance. Unless otherwise noted, organizations must meet the requirements throughout the lookback period. NCQA applies the Renewal Survey look-back period for programs that existed during the organization s last survey and are being brought forward for the first time. NCQA measures the look-back period from the point of the organization s submission of the completed Survey Tool. Specific requirements that the organization must meet, and guidance for demonstrating performance against the elements. Descriptive information illustrating performance against an element s requirements. Examples are for guidance only and are not specifically required or all-inclusive. Summary of Changes General Separated physician quality standard (previously PHQ 1) into four separate standards (PQ 1 PQ 4). Previous PHQ 2 is now HQ 1. Changed level of review from organization level to program level. Policies and Procedures Eliminated the Corporate Survey. New Elements, Factors PQ 1, Element D: Revised the element and removed a factor. PQ 3, Element A: Combined two previous elements into Element A. PQ 4, Element C: Requires programs to continuously improve through a monitoring process and routine updates, including identifying areas for improvement (factor 1) and acting on them (factor 2). Refer to Appendix 5: Crosswalk and Summary of Changes for For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

10 4 Overview Where to Find Specific Information The Standards and Guidelines include policies and procedures, standards and elements, scoring guidelines and appendices. See the Policies and Procedures for... Information on organizations eligible for NCQA Certification. Responsibilities of organizations seeking certification. certification status information. Information on applying for certification. Information on the Survey Tool. Information on the survey process. Information on attaching documents and submitting the Survey Tool. See the Certification Standards, Organized by Category, for The standards. The intent of the standards. A summary of changes from the previous standards year. Elements and scoring guidelines that describe the requirements for an organization to achieve different performance levels for each element. Data sources used to demonstrate compliance with an element. The scope of review. The look-back period. An explanation of expectations for demonstrating performance against the element s requirements. See the Appendices for Summary tables of PHQ standard and element points (Appendix 1). A glossary (Appendix 2). Interim survey requirements (Appendix 3). A description of credit for organizations that use (Appendix 4). A crosswalk and summary of changes (Appendix 5). A description of the New York Ratings Examiner requirements (NYRx) (Appendix 6) PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

11 Overview 5 Other NCQA Accreditation, Certification, Recognition and Evaluation Programs NCQA offers the following accreditation programs: Health Plan (HP). Managed Behavioral Healthcare Organization (MBHO). Disease Management (DM). Wellness & Health Promotion (WHP). Accountable Care Organization (ACO). Case Management (CM) NCQA offers the following certification programs: Credentials Verification Organization (CVO). Disease Management (DM). Health Information Products (HIP). Certification in Utilization Management and Credentialing (UM-CR).* *This program replaced OC-UM, OC-CR and POC in NCQA offers the following recognition programs: Diabetes Recognition (DRP). Heart/Stroke Recognition (HSRP). Physician Practice Connections (PPC). Patient-Centered Medical Home (PCMH) NCQA offers the following evaluation programs: New York Ratings Examiner Reviews (NYRx). NCQA offers the following distinction program: Multicultural Health Care (MHC). Patient Experience Reporting (for NCQA-Recognized Patient-Centered Medical Homes). For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

12 PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

13 Physician and Hospital Quality Policies and Procedures

14 PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

15 Policies and Procedures Section 1: Eligibility and the Application Process 9 Section 1: Eligibility and the Application Process Summary of Changes November 20, 2017: Added a note under Organization Obligations that Discretionary Surveys review the organization against the standards in effect at the time of the Discretionary Survey. Updated the NCQA address to th Street NW, Third Floor Washington, DC under Applying for an NCQA Survey Application request. Revised the language under Survey application to refer to the provision of the Agreement for Physician and Hospital Quality Certification Survey and the Business Associate Agreement. Eligibility for Certification Many types of organizations can perform the activities evaluated in PHQ and are therefore eligible for certification. There is no requirement that organizations hold any other accreditation or certification from NCQA. Eligible organizations include, but are not limited to: Health plans. Provider networks. Collaborative measurement organizations. Information providers. Eligibility criteria Any organization interested in applying for an NCQA PHQ Certification Option must meet the following criteria, as applicable: The organization must operate a physician measurement program or hospital transparency program, as defined below. Physician measurement programs are eligible for physician quality certification or interim physician quality certification. Hospital transparency programs are eligible for hospital quality certification. The organization must be responsible for responding to complaints from consumers and to requests for changes from physicians or hospitals based on the actions the organization takes The organization must either perform or contract for all functions in the standards, unless an element lists a not applicable (NA) option in the scoring. The organization must have completed at least one cycle of measurement and taking action on the results, unless applying for interim physician quality certification. The organization must comply with applicable federal, state and local laws and regulations, including any licensure requirements. The organization operates without discrimination based on sex, race, creed or national origin. For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

16 10 Policies and Procedures Section 1: Eligibility and the Application Process Defining a program A physician measurement program includes: A defined group of physicians. The definition must include both physician type (e.g. specialty) and geographic area covered. A defined set of clinical quality, service or patient experience measures. The program may also include a defined set of cost, resource use or utilization measures. A defined methodology for producing measure results. A specific action taken at a specific point in time based on the measure results. Refer to Taking Action on Measurement Results, below. A hospital transparency program includes: A defined group of hospitals. The definition must include both hospital type and location. A defined set of all-payer quality or cost measures whose results are publicly reported at a specific point in time. Throughout these policies and procedures, NCQA uses the term program to refer to both types of programs, unless a policy applies to physicians only or to hospitals only. Distinct programs are reviewed separately and a certification decision is issued for each. Physician measurement programs and hospital transparency programs are always distinct programs, even when operated by the same legal entity. NCQA reserves the right to determine that programs that are managed in a decentralized manner constitute distinct programs for review. To the extent that two programs share common aspects (e.g., an organization uses the same measures and methodology for a single defined physician group but takes two actions [reporting and network tiering]), NCQA can review common aspects once to streamline the survey process, although these are distinct programs. Taking action on measurement results NCQA defines taking action as: Publicly reporting performance on quality or cost, resource use or utilization. Using performance on quality or cost, resource-use or utilization measures as a basis for network design (such as tiering) or benefit design. Using performance on quality or cost, resource-use or utilization measures to allocate rewards under a systematic, pay-forperformance program. Reporting performance on quality, cost, resource use or utilization to physicians to support referral decisions. Taking action does not include: Paying physicians or hospitals to participate in measurement reporting, because payments are not based on performance PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

17 Policies and Procedures Section 1: Eligibility and the Application Process 11 Price transparency, where an organization publicly reports the unit price for a specific service or treatment from a specified provider (i.e., the amount charged, the negotiated rate paid by the organization or the amount paid by the consumer). Unit price is not a measure of performance. Quality improvement activities such as sharing their own results with physicians or hospitals and helping them improve, where there is no public reporting or other broad implication (such as network design). How NCQA Defines an Organization for Certification NCQA defines the organization (also called the certifiable entity) based on the legal entity, the management structure and the program implemented. NCQA s goal is to identify the organization responsible for operating the discrete program. Given the variety of organizational structures and ownership among those applying, identifying the certifiable entity requires understanding specifically how the organization operates the program. NCQA considers the following factors when determining the certifiable entity for certification. Note: NCQA may be able to conduct components of the review centrally for multiple certification decisions. Legal entity Centralization NCQA s goal is to identify the legal entity that measures and acts on quality or cost for a defined set of providers. If the organization consists of multiple legal entities within a state but otherwise operates as a single statewide organization, NCQA awards certification decisions for each legal entity, but the organization may submit one statewide application that is applied to each legal entity. Operating as a single statewide organization means having the same management structure, a single practitioner/provider network for the entire state and centralized key functions, including measurement and taking action on results of measurement. NCQA considers the degree of centralization of key functions assessed by the certification standards. Organizations often have a single measurement program and a single set of policies and procedures for the actions they take based on measurement. In this case, the organization is one certifiable entity. Other organizations have key functions decentralized, and different units within the organization have different policies and procedures for those key functions. In that case, NCQA may determine that there is more than one certifiable entity. Collaborative measurement activities Collaborative measurement activities (collaboratives), which combine data from multiple organizations to produce provider measurements, have two choices for participation in PHQ certification. A collaborative may: Apply for certification as a certifiable entity, if it can meet the eligibility requirements. Undergo a centralized, collaborative survey for only the functions it performs, making the results available for its participating organizations. For example, the collaborative may combine data from its participants to measure providers, making the results available to its participants, which are certifiable entities. Participants may use results of the collaborative s survey to demonstrate performance on portions of the PHQ standards and elements. For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

18 12 Policies and Procedures Section 1: Eligibility and the Application Process Right to Decline to Survey NCQA reserves the right to decline to survey an organization or to suspend an ongoing survey, if it determines that the organization does not meet the criteria. NCQA makes every effort to determine whether an organization meets the criteria in advance of a survey; however, if NCQA determines during a survey that an organization does not directly conduct or contract for the activities required by the standards, NCQA reserves the right not to proceed with the survey or to withhold certification. Organization Obligations By applying for any PHQ Certification Option and thereby applying for an NCQA Survey, the organization agrees to be bound by the Agreement for Physician and Hospital Quality Certification Survey (the Agreement ). As a part of the certification process, the organization must: Purchase a license to access and use the NCQA Web-based Interactive Survey System (ISS) Survey Tool. Identify the programs for which it seeks certification. Agree to continue to meet the requirements of the applicable NCQA Standards and Guidelines throughout the entire period an NCQA Certification status on those standards is valid. Note: If NCQA conducts a Discretionary Survey, it reviews the organization against the standards in effect at the time of the Discretionary Survey. The organization is obligated to complete the certification process once the survey begins. Applying for an NCQA Survey Application request The organization must submit an application for a PHQ survey. Applications for Certification Surveys can be ordered online at no charge at or by contacting NCQA Customer Support at: National Committee for Quality Assurance th Street NW, Third Floor Washington, DC To complete the application, the organization must identify the programs for which it seeks certification. The completed application includes relevant information on the organization, including functions covered in the standards that are: Performed by the organization. Performed by the organization for other organizations. Performed at a centralized level. Performed by a collaborative on behalf of the organization. Performed by a contracted organization. Carved out by purchasers or employers. This information helps NCQA structure the survey around the operational characteristics of the organization. Survey application NCQA encourages organizations to submit applications well in advance of their desired survey date. Organizations should submit the survey application, the application fee and the signed Agreement at the same time, and at a minimum of nine months before their desired survey date. The survey date is the date when the organization submits its completed Survey Tool and documents to NCQA and 2013 PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

19 Policies and Procedures Section 1: Eligibility and the Application Process 13 begins the formal survey process. If an organization submits complete materials less than nine months before it wants to be surveyed, NCQA may not be able to accommodate the requested survey date. NCQA does not begin to process an application or schedule survey dates until the organization has satisfied all requirements for the application and has submitted the application and supporting attachments, the coverage area report, a signed current Agreement for Physician and Hospital Quality Certification Survey, Business Associate Agreement and the application fee. To avoid delays in application processing resulting from submission of out-of-date applications and agreements, the organization must request an application from the NCQA Publications Department no more than 30 days in advance of when it plans to submit its application materials. Unless state or other applicable law requires modifications, all organizations are expected to sign NCQA s legal agreements. Requests to change the standard agreements due to legal conflicts must be approved by NCQA, and must be submitted with evidence of the legal conflict at least 12 months before the survey date. Survey fee All pricing policies and survey fees are specified in Exhibit A of the Agreement. For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

20 14 Policies and Procedures Section 2: The Certification Process Section 2: The Certification Process Summary of Changes July 29, 2013 Added Expedited Survey subhead and text. Components of Certification Certification Options The PHQ certification product contains three certification options: 1. PQ certification. This option is appropriate for physician measurement programs. 2. HQ certification. This option is appropriate for hospital transparency programs. 3. Interim PQ certification. This option is appropriate for physician measurement programs where the organization has not yet taken action. Refer to Interim PQ Certification. How Organizations Are Evaluated NCQA evaluates organizations, by program, on their performance against the certification standards for each certifiable entity. NCQA awards a separate certification decision to the organization for each program it brings forward. Certification Status Certification is based on a program s compliance with the standards and elements required for the specific certification option. Certification status is based on the organization s overall standards score for each program, on NCQA s assessment and on the final determination of NCQA s Review Oversight Committee (ROC), an independent review committee that comprises physicians external to NCQA. The organization receives a Certificate of Certification and seals for each program certified by NCQA, with the applicable dates of its certification status. Assessment NCQA assesses the organization against applicable standards for each program brought forward. Each element in each standard has a point value; NCQA evaluates each element separately and assigns a performance level of 100%, 80%, 50%, 20% or 0%. The organization receives the assigned percentage of the maximum element points based on the assigned performance level. The total points received for the standard is the sum of the points received for each element. The total possible point value for the standards in PQ and HQ certification options is 100 points. Refer to Appendix 1: Standard and Element Points for The total possible point value for the standards for NCQA Interim PQ Certification is An organization may advance from interim PQ certification to PQ certification through the Interim Follow-Up Survey. Refer to Interim PQ Certification. An NCQA Certification Survey results in one of the following outcomes outlined in the table below. Scoring thresholds associated with each status are also shown in the table below. Earning any level of certification requires achieving the necessary point score and passing all must-pass elements. Refer to Adjusting Certification Status PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

21 Policies and Procedures Section 2: The Certification Process 15 Accreditation Status Certified Interim Certification Denied The organization s responsibility Standards Score At least 70% of possible points on PQ or HQ standards and meets applicable must-pass requirements. At least 80% of possible points on the applicable elements from PQ standards, Measuring Physician Performance, Elements (PQ 1, Elements A G; PQ 2, Elements A C; PQ 3, Elements A C; PQ 4, Element A) and meets applicable must-pass requirements. Elements PQ 3D, PQ 4B and PQ 4C are not reviewed or scored during the Interim Survey. Less than 70% of the possible points on applicable standards or failure to meet must-pass requirements. The organization must: Identify the scope for which it seeks certification, including: Program and activities undertaken (e.g., measurement, reporting, quality improvement, benefits related or payment related). Types of providers covered (i.e., physicians, hospitals). Status of its ongoing program and indicate the type of certification sought, if applicable. Undergo a Certification Survey at least once every two years to evaluate the program against the applicable NCQA standards to maintain certification. For interim PQ certification status, undergo an Interim Follow-Up Survey within 180 days of receiving the status and must submit the survey before the earliest of one of the following: 120 days after the organization publicly announces its planned actions (e.g., announces to consumers its intent to tier or publicly report results), or 120 days after action occurs. Disclaimer The scoring guidelines in the Survey Tool are not binding on NCQA, its surveyors, the ROC, the NCQA Reconsideration Committee or any other NCQA decision-making body. Interim PQ Certification NCQA uses the following criteria to determine Interim PQ Certification. Eligibility Availability Application Survey The organization has a physician measurement program but has not yet announced planned action or taken that action. Interim certification is not available to organizations that publicly release their program before coming forward for survey. Interim PQ certification is available to organizations that meet eligibility requirements. Organizations must apply for interim PQ certification when they submit the application for survey. NCQA conducts two surveys: an Interim Initial Survey and Interim Follow-Up Survey. Organizations pursing PQ Certification are assessed against the PQ standards over the two-survey process. For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

22 16 Policies and Procedures Section 2: The Certification Process Applicable elements Interim Initial Survey Scoring If the organization seeks Interim PQ Certification, NCQA scores the program against the following elements of PQ. The following elements receive a final score: PQ 1, Elements A C and E G. PQ 2, Elements A C. PQ 3, Element C. PQ 4, Element A. The following elements receive an interim score: PQ 1, Element D. PQ 3, Elements A, B. The following elements are not reviewed or scored: PQ 3, Element D. PQ 4, Elements B, C. Interim Survey standards and elements PQ 1: Measures and Methods Element A: Standard Quality Measures. Element B: Measuring Cost. Element C: Define Methodology. Element D: Adhere to Key Principles. Element E: Frequency. Element F: Verifying Accuracy. Element G: Results Reflect Data Beyond a Single Payer. PQ 2: Working With Physicians Element A: Transparency of Measures and Methods. Element B: Opportunity to Correct. Element C: Handing Requests for Corrections or Changes. PQ 3: Working With Customers Element A: Transparency of Measures and Methods. Element B: Scope of Transparency With Customers. Element C: Policies and Procedures for Complaints. Element D: Handling Complaints. PQ 4: Program Input and Improvement Element A: Seeking Input During Development. Element B: Feedback on Reports. Element C: Program Impact PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

23 Policies and Procedures Section 2: The Certification Process 17 Interim Follow-Up Survey scoring and standards and elements Achieving interim PQ certification Achieving PQ certification Certification duration The following elements receive a final score: PQ 1, Element D. PQ 3, Elements A, B are rescored. PQ 3, Element D. PQ 4, Elements B, C are scored. An organization that meets the must-pass requirements and achieves at least 80 percent of the points on the following elements is eligible for interim PQ certification: PQ 1, Elements A G. PQ 2, Elements A C. PQ 3, Elements A C. PQ 4, Element A. An organization that meets the must-pass requirements and scores at least 70 percent of the points on the PQ elements is eligible for PQ Certification. Interim PQ certification is valid for 180 days upon the certification status effective date. To achieve PQ certification without a lapse in status, the organization must begin an Interim Follow-Up Survey before the end of the 180 days and within no more than 120 days of taking action. PQ certification is effective for two years and is retroactive to the date when the organization received interim certification status; not the date the organization advanced from Interim Certification to PQ Certification. Expiration of certification status Organizations may apply for certification after a lapse in certification status. Adjusting Certification Status Denial of certification Denial of certification occurs when NCQA finds that the organization is not in compliance with the requirements of the PQ standards. Denial of certification can also occur when, in NCQA s judgment, a deficiency poses a potential risk to the health and safety of patients. NCQA does not publish the names of organizations denied certification. If the organization seeks another Certification Survey, NCQA evaluates the organization under the standards in effect at the time of the new survey. Must-pass elements The organization is denied certification if it receives less than a 50% score on any of the following must-pass elements that are included in its certification option: PQ 1, Elements A, C, F, D. PQ 2, Elements A, B. PQ 4, Element A. For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

24 18 Policies and Procedures Section 2: The Certification Process For HQ certification only, the organization is denied certification if the it receives less than a 50% score on any of the following must-pass elements: HQ 1, Element A: Hospital Performance Data. HQ 1, Element B: Decision Support Tools. HQ 1, Element C: Availability of Information to Customers. HQ 1, Element D: Scope of Hospitals. HQ 1, Element E: Working With Hospitals on Reporting. HQ 1, Element F: Information About Measurement. HQ 1, Element G: Feedback on Customer Reports. ROC determination The organization is denied certification if the ROC agrees that the organization failed a must-pass element. Certification Survey Types NCQA offers four types of surveys to organizations seeking certification for the three certification options (PQ certification, HQ certification, interim PQ certification): 1. Certification Survey: Initial Survey. Renewal Survey. 2. Collaborative Survey. 3. Collaborative Participant Survey. 4. Add-On Survey. Refer to Section 3: The Survey Process for more information. During a Certification Survey, NCQA evaluates the organization s programs for provider measurement and action against the relevant standards. For PQ Certification, only PQ standards are relevant. For HQ Certification, only the HQ standard is relevant. Refer to Interim PQ Certification for applicable survey types for that option. Certification Survey Initial Survey Renewal Survey Organizations that have never completed a Full Survey undergo an Initial Survey. Before an organization s certification expires, it must complete another Agreement, submit all requisite fees and undergo a Full Survey, called a Renewal Survey, to renew its certification status. When the organization receives its Initial Survey results, NCQA assigns a date for the Renewal Survey. Even if the organization s measurement program remains the same over time, the organization can receive a denial of certification on a Renewal Survey. This may happen if the organization s processes have not been maintained or if the organization has not adapted to changes in certification standards. NCQA reviews the organization using the standards in effect at the time of the Renewal Survey PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

25 Policies and Procedures Section 2: The Certification Process 19 Collaborative Survey A Collaborative Survey is similar to a Corporate Survey, where the collaborative provides centralized functions on behalf of organizations that participate in the collaborative measurement initiative. There are active collaboratives in several states or regions of the country. To be eligible for a Collaborative Survey, a collaborative must meet the following criteria: Have a legal entity that can enter into a survey contract with NCQA. Have a person who is authorized to act on behalf of the collaborative. Have a designated contact to work with NCQA on aspects of the survey, including scheduling the survey and completing and submitting the collaborative s Survey Tool. NCQA considers an organization to be a participant in a collaborative if the collaborative has completed data collection for at least one cycle of measurement at the time of the organization s survey and the organization s data are included in the measurement. Measurement collaboratives may choose one or both of these options: Apply for certification as a certifiable entity and undergo a Certification Survey. If a collaborative applies as a certifiable entity, the results are the same as under a Certification Survey. Undergo a Collaborative Survey of a subset of the PHQ elements, to allow participants in the collaborative to use the survey results. If a collaborative applies as a certifiable entity, the results are the same as above under a Certification Survey. If the organization undergoes a Collaborative Survey only, the results are available to participants and NCQA does not render a decision. If the organization undergoes a Collaborative Survey to allow collaborative participants to use survey results, NCQA s contract requires the collaborative to permit NCQA to use the survey results for any participant to demonstrate performance against certain standards or elements. The survey process When the collaborative applies for survey, it proposes specific standards and elements for review, including its rationale for a survey at the collaborative level. NCQA reviews the proposal and makes a final decision about the standards and elements it will review for the collaborative. The collaborative purchases and completes a Survey Tool and assembles materials demonstrating how it meets standards on behalf of participating organizations. The collaborative submits the materials to NCQA for survey using the Survey Tool. NCQA Surveys the collaborative for the specified elements and issues results for those elements. The collaborative may request Reconsideration of the results. Refer to Section 4: Additional Information. Duration of survey results Results of a Collaborative Survey are in effect for two years from the date when results are final or until the effective date of a revised version of the PHQ standards, whichever is sooner. Results may be applied to any participant surveyed during the effective-date period. For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

26 20 Policies and Procedures Section 2: The Certification Process Eligibility of functions Functions developed or performed by the collaborative and used by any participating organization are eligible for review during a Collaborative Survey. NCQA applies results of the specified elements to all organizations that: Qualify as participants in the collaborative. Seek any PHQ Certification Option during the period when the Collaborative Survey results are valid. Agree to use Collaborative Survey results. Collaborative Participant Survey Each collaborative participant is a separate, certifiable entity that must apply for its chosen certification options and submit its own contract; each participant receives its own certification decision. All participants that use the results of a Collaborative Survey agree to such use in a signed Agreement with NCQA. NCQA surveys collaborative participants for elements that are not fully addressed in the scope of the Collaborative Survey, and combines the results with Collaborative Survey results. Although all elements may be reviewed at the collaborative level, each collaborative participant must submit its own Survey Tool. Collaborative participants may take action based on measures that are not part of the collaborative, and may take actions that are not taken by the collaborative. The score for each element is based on the performance of both the participant and the collaborative. If a participant uses collaborative results for its NCQA Survey but the collaborative does not fully meet an element, the participant must accept the score and may not appeal the results. An organization that joins a collaborative after the collaborative has been surveyed may use the survey results if it demonstrates that its data were included in both the measurement and the reporting conducted by the collaborative. Renewing Collaborative Survey results Collaborative Survey results must be renewed every two years or when revised standards go into effect, in accordance with current standards. The collaborative organization may propose additional standards for inclusion at renewal. Additional standards scored at the collaborative level are not applied to an affiliate or participant until its next survey. Add-On Survey If an organization expands the scope of its program, it must notify NCQA to determine if the expanded scope is subject to an Add-On Survey. Examples of expanding scope include, but are not limited to: Expanding the scope of actions geographically. The organization is a health plan that does business in all of New York State. At the time of its Certification Survey, it has a tiered physician network in downstate New York only. Six months after achieving NCQA Certification, the organization adds a tiered physician network in upstate New York. Expanding the scope of physician specialties affected. The organization is an information provider. At the time of its Certification Survey, it is surveyed based on a public reporting program that pertains only to specialists. One year after achieving NCQA Certification, the organization adds primary care physicians to its program. Refer to Section 1: Eligibility and the Application Process PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013

27 Policies and Procedures Section 2: The Certification Process 21 Expedited Survey Although an organization with Denied Certification status may not reapply for accreditation/certification until one year from the date of the Denied status, there are certain circumstances under which an organization may apply for a new Certification Survey in less than a year. These surveys are called Expedited Surveys. An Expedited Survey is a full-scope survey. The look-back period for an Expedited Survey is six months. The organization is reviewed against the standards and guidelines in effect at the time of the Expedited Survey. The organization must provide documentation for all requirements; documentation may have been submitted previously or may be new. The organization may bring forward new programs that were not included in the original submission. To qualify for an Expedited Survey, the organization must first submit a written request listing the steps it has taken to address the substantive issues that led to Denied Certification status. Upon receiving an organization s request, NCQA may, at its sole discretion, grant a request for an Expedited Survey in less than one year, in the following circumstances: The organization demonstrates to NCQA s satisfaction that it can resolve the issues identified in the original survey in less than one year and that the correction of the issues would raise the organization s certification status in a new survey. There are licensure or regulatory consequences associated with Denied Certification status. Reporting Certification Results to the Public NCQA provides the organization with a version of the Survey Tool that includes the final scores on all elements, standards and categories. The NCQA Web site reports on and lists organizations with NCQA PQ Certification, HQ Certification and Interim PQ Certification. Release of survey results by NCQA Release of NCQA Survey results by the organization NCQA makes Certification Survey results available to the public, but does not release information on denials. Refer to Reporting Certification Status to the Public. NCQA does not release confidential information prepared or reviewed during the certification process to any third party, except in the following circumstances: With prior written authorization from the organization. As otherwise required by law, regulation or court order. As otherwise provided in the NCQA policies and procedures or the Agreement. Release of NCQA Survey results by the organization must be in accordance with NCQA policies and procedures and the Guidelines for Advertising and Marketing. NCQA considers the following to be components of the final certification results: The completed Survey Tool. A description of overall performance and certification status. Summarized and detailed standard results: By category. By standard in a category. By element for each standard in a category. Additional descriptive information from the Final Results. Refer to Reporting Status to the Public. For Surveys Beginning On or After July 1, PHQ Standards and Guidelines

28 22 Policies and Procedures Section 2: The Certification Process At its discretion, the organization may release any of the following components of the final certification results to third parties: The final results, in their entirety, as defined above, with or without the Survey Tool attachments. A description of overall performance and certification status. Detailed results: By category. By standards in a category. By element for each standard in a category. The organization may not use, disclose, represent or otherwise communicate reports or numeric results from the readiness evaluation to any third party for any other purpose, or represent that it is NCQA Certified based on reports or numeric results, without a final NCQA decision. Marketing certification results An organization that elects to market its certification status must do so in accordance with the NCQA Guidelines for Advertising and Marketing. Marketing materials should not imply that individual certification decisions apply beyond the certified entity. Reporting Certification Status to the Public NCQA publicly reports the organization s certification results by program. Right to release and publish NCQA reserves the right to release and publish, and to authorize others to publish: The organization s certification status. Results of the organization s performance under specific standards and elements, including factors of an element that are met or are not met. The names of the NCQA-Accredited or NCQA-Certified organizations with which the organization contracts. Aggregate data based on Certification Surveys NCQA has performed. Additional descriptive information from the Final Results. In many cases, the organization s score on an element or factor is sufficient to explain how the organization approaches a specific requirement. In other cases, NCQA may need to report this additional descriptive information to give physicians and consumers a clear picture of the organization s results. NCQA reserves the right to use data collected from Certification Surveys, and to authorize others to use such data, in connection with information products and decision support tools, for NCQA s research and development purposes and for other purposes as agreed to by the organization in the contract. An organization that dissolves or ceases to exist is removed from the public reporting list PHQ Standards and Guidelines For Surveys Beginning On or After July 1, 2013