Organizations will submit one data file to capture all timeliness data elements.

Transcription

1 Appendix 3: UM Notification of s Recommendations 1 Note: This document provides recommendations for changes to UM 5, Element B: Notification of Nonbehavioral s. The proposed changes also apply to: UM 5, Element D: Notification of Behavioral Healthcare s UM 5, Element F: Notification of Pharmacy s UM 9, Element B: Timeliness of the Appeal Process Organizations will submit one data file to capture all timeliness data elements. UM 5, Element B: Notification of Nonbehavioral Healthcare s The organization adheres to the following time frames for notification of non-behavioral healthcare UM decisions for at least 90% of decisions for each decision-type: 1. For commercial and Marketplace urgent concurrent decisions, the organization gives electronic or written notification of the decision to practitioners and members within 24 hours of the request. 2. For Medicare and Medicaid urgent concurrent decisions, the organization gives electronic or written notification of the decision to practitioners and members within 72 hours of the request. 3. For urgent preservice decisions, the organization gives electronic or written notification of the decision to practitioners and members within 72 hours of the request. 4. For nonurgent preservice decisions, the organization gives electronic or written notification of the decision to practitioners and members within 15 calendar days of the request. 5. For post-service decisions, the organization gives electronic or written notification of the decision to practitioners and members within 30 calendar days of the request. Scoring 100% 80% 50% 20% 0% High (90-100%) on file No scoring option Medium (60-89%) on file No scoring option Low (0-59%) on file Met Partially Met Not Met The organization meets 2-3 factors The organization meets 4 factors The organization meets 0-1 factors Data source Scope of Records or files Reports, Electronic Data Format This element applies to Full and Streamlined Surveys. NCQA s this element for each product line brought forward for Accreditation. The universe of data must include all accredited and non-accredited delegates in the electronic data file the organization submits to NCQA. NCQA s the universe of raw data (including all approvals and denials) for utilization management decisions resulting from medical necessity (as defined in UM 1, Element A) during the look-back period for evidence of compliance

2 Appendix 3: UM Notification of s Recommendations 2 with timeliness of decision/notification requirements. NCQA requires organizations to submit raw data as outlined below in Reporting Requirements. NCQA will use the submitted data to calculate and score compliance with the timeliness standards for each category (behavioral, non-behavioral, pharmacy and appeals) and type. Each type will be scored per product line for compliance. Review types are defined within standards and guidelines and include the following: 1. Urgent Concurrent Initial s 2. Urgent Preservice Initial s 3. Nonurgent Preservice Initial s 4. Postservice Initial s 5. Preservice Appeals 6. Postservice Appeals 7. Expedited Appeals Explanation How to create and submit the electronic data file NCQA will supply the organization with an electronic csv file format. Every organization will utilize the same defined file format. One file will be submitted by the organization which will include any delegate files. The organization extracts data from its own and its delegates operating systems where utilization management data is captured: o The electronic data file must include all requests (both approvals and denials) processed as Utilization Management requests (full universe report) resulting from medical necessity. o If an organization delegates Utilization Management decisions, the organization will submit data from the delegate for scoring. The organization submits the csv file to NCQA. How NCQA will calculate rates NCQA will calculate turnaround time for each factor based the definitions outlined in the Explanation section of UM 5: Timeliness of UM s and UM 9: Timeliness of the Appeal Process, exceptions and other related information sections. Each type will be scored by product line for compliance with the associated timeliness standard. Review types are defined as: o Urgent Concurrent Initial s o Urgent Preservice Initial s o Nonurgent Preservice Initial s o Post-service Initial s o Preservice Appeals o Post-service Appeals o Expedited Appeals The fields in the organization s operating systems may not be an exact match to NCQA language. To provide accurate data to NCQA, the organization must map their system fields to NCQA s data element definitions as described in the table below.

3 Appendix 3: UM Notification of s Recommendations 3 Project Codes Field Data Definition Field Format Represents the project code associated with the Accreditation Product Line of Business (LOB) Indicates the line of business associated with the classification Assigned NCQA Accreditation Program Code (e.g. PRJ = Medicare 2 = Medicaid 3 = Marketplace 4 = Commercial Delegate File File conducted by delegate Y = Yes Delegate Accreditation Indicator Yes or No indicator to indicate if delegate is accredited by NCQA for Utilization Y = Yes Delegate Name Review Classification Review Category Note: Organizations will submit one data file to capture all timeliness data elements Request received date Extension indicator Extension date Final Management or Health Plan Accreditation Indicate the Name of delegate responsible for Utilization Management decision The type of being performed as defined in NCQA standards and guidelines classification of UM requests. a. Urgent Concurrent initial decision b. Urgent Preservice initial decision c. Nonurgent Preservice initial decision d. Post Service initial decision e. Pre - Service Appeals f. Post Service Appeals g. Expedited Appeals Represents the category of the classification a. Non-Behavioral Health b. Behavioral Health c. Pharmacy d. Appeal The date received is the date when to organization receives the request from the member or the member s authorized representative. Received dates are automated by the system upon creation of the request. If the request is not entered in the system at time of receiving the request, indicate the actual date received. Indicator of appropriate extension criteria being met and applied to for appropriate turn around time calculation To be determined 1 = Urgent Concurrent Initial 2 = Urgent Preservice Initial 3 = Nonurgent Preservice Initial 4 = Post Service Initial 5 = Pre Service Appeal 6 = Post Service Appeal 7 = Expedited Appeal 1 = Non-Behavioral Health 2 = Behavioral Health 3 = Pharmacy 4 = Appeal MM/DD/YYYY Y = Yes Date organization received response or date MM/DD/YYYY at the end of the extension period. Indicates the final determination regarding 1 = Approved the medical necessity determination 2 = Denied a. Approved 3 = Withdrawn b. Denied c. Withdrawn

4 Appendix 3: UM Notification of s Recommendations 4 date Oral Notification date Member Oral Notification date - Practitioner Written Notification date Member Written Notification date Practitioner Electronic Notification date - Member Electronic Notification date - Practitioner Notification Exception indicator Date of the final medical necessity MM/DD/YYYY determination Date organization provided oral notification MM/DD/YYYY of utilization management decision to member Date organization provided oral notification MM/DD/YYYY of utilization management decision to the practitioner Date organization provided written MM/DD/YYYY notification of utilization management decision to member and / or attending or treating practitioner. Date organization provided written MM/DD/YYYY notification of utilization management decision to member and / or attending or treating practitioner. This would include electronic notification MM/DD/YYYY date, web portal posting date if used to notify Member through portal This would include electronic notification MM/DD/YYYY date, web portal posting date if used for notification to practitioner through portal Not required to notify the member of a Y = Yes concurrent decision (UM 5B factor 1&2 and factor 5) if the member is not at financial risk.

5 Appendix 3: UM Notification of s Recommendations 5 UM 5, Element X: Data Validation To validate the accuracy of the data submitted to support electronic scoring of timeliness, the organization: 1. Provides an attestation signed by the organization s Chief Executive Officer or Chief Medical Officer affirming submission of accurate, complete, original Utilization Management data that has not been altered to meet NCQA or other regulatory standards. 2. Incorporates system features to prevent fraud, including inability to adjust dates associated with Utilization Management activity, for each operational system used by the organization to perform utilization management activity. 3. Has a policy outlining fraud prevention strategy specific to dates associated with utilization management operating systems. Data source: Scope of Explanation Documented process, Reports This element applies to Full and Streamlined Surveys. NCQA s this element for each product line brought forward for Accreditation. During onsite or virtual, the NCQA surveyor will audit the organization s utilization management systems and electronic audit log to evaluate the accuracy of dates associated with utilization management turnaround time compliance. The organization audits its delegates operating systems.