The Mihalik Blog

HEDIS® Public Comment Open

Last week, NCQA opened the public comment periodon proposed changes to HEDIS 2010. 

 

A new CAHPS measure, Aspirin Use and Discussion, is proposed.  The measure will include rates for Current Aspirin Use and Discussing Aspiring Risks and Benefits (with a doctor or provider).

 

Changes are proposed to the following measures:

·         Years in Business/Total Membership

·         Medical Assistance with Smoking Cessation

·         Colorectal Cancer Screening

·         Appropriate Treatment for Children with Upper Respiratory Infection

·         Use of Appropriate Medications for People with Asthma

 

There also are proposed changes to Technical Specifications and Specifications for Survey Measures.

 

The public comment period lasts until March 17, 2009. 

 

  

 

 

Practitioner Communication Requirements for Behavioral Health

This is the last in a series of blogs on NCQA’s communication requirements.  NCQA did not release MBHO standards for 2009.  The 2008 standards remain in effect.    

 

Items that must be communicated annually:

·         Information about the quality improvement program including goals, processes, and outcomes as related to care and service (QI 2C.2).

·         New preventive behavioral health information to existing practitioners and providers (PH 2A).

Items that must be communicated on joining the network and annually thereafter:

·         The member rights and responsibilities statement (RR 2A.3 and RR 2A.4).

Items that must be communicated once since the prior survey:

·         The organization’s policy prohibiting financial incentives for utilization management decision-makers (UM 4E.1, UM 4E.2, and UM 4E.3).

Items with no specified frequency of communication (I recommend annual):

·         Distribution of the organization’s adopted clinical practice guidelines to all appropriate practitioners (QI 7A.4).

·         A description of the organization’s treatment record policies including requirements for: confidentiality of treatment records, documentation standards, systems for organization of treatment records, standards for availability of treatment records at the practice site, and performance goals to assess the quality of medical record keeping.  A documented process describing treatment record policies and how the information is distributed to practitioners is also required (QI 12A.1, QI 12A.2, QI 12A.3, and QI 12A.4).

·         Information about the medical necessity criteria, including how to obtain or view a copy (UM 2 B.1).

·         The toll-free number to contact staff regarding UM issues (UM 3A.5).

·         The availability of staff to answer questions about the UM process (UM 3A.6).

·         The availability of, and process for, contacting an appropriate peer reviewer to discuss utilization management decisions (UM 7A.1 and UM 7A.2).

·         A description of the process to review information submitted to support a practitioner’s credentialing application, correct erroneous information and, upon request, to be informed of the status of the credentialing or recredentialing application.  A documented process describing the processes and how the information is distributed to practitioners is also required (CR 1B.1, CR 1B.2 and CR 1B.3).

Distribution in a timely fashion following revisions:

·         Revised preventive health information to existing practitioners and providers (PH 2B).

Distribution in a timely fashion following revisions after practitioner or provider joins network:

·         Preventive health information to new practitioners and providers (PH 2C).

Member Communication Requirements for Behavioral Health

My last two blogs have been on NCQA’s member communication and practitioner communication requirements for health plans.  I thought I’d round out the series by doing the same for managed behavioral health care organizations. 

Because of the differences in the Health Plan and Behavioral Health standards, the communication requirements are different. 

 

Items that must be communicated annually:

·         Information about the quality improvement program including goals, processes, and outcomes as related to care and service (QI 2C.1).

·         A description of the availability of an independent external appeals process for utilization management decisions made by the organization (UM 8D.2 and UM 8E.1).

 Items that must be communicated on enrollment and annually thereafter:

·         The member rights and responsibilities statement (RR 2A.1 and RR 2A.2)

·         Information about benefits and services included in, and excluded from, coverage (RR 4A.1).

·         Information about copayments and other charges for which the member is responsible (RR 4A.2).

·         Information about restrictions on benefits that apply to services obtained outside the organization’s system or service area (RR 4A.3).

·         Information about how the member may submit a claim for covered services, if applicable (RR 4A.4).

·         Information about how the member may obtain information about network practitioners, including professional qualifications of primary and specialty care practitioners (RR 4A.5).

·         How the member may obtain inpatient and outpatient services, partial hospitalizations and other behavioral healthcare services (RR 4A.6).

·         How the member may obtain subspecialty care (RR 4A.7).

·         How the member may obtain care after normal office hours (RR 4A.8).

·         How the member may obtain emergency care, including the organization’s policy on when to directly access emergency care or use 911 services (RR 4A.9).

·         How the member may obtain care and coverage when he or she is out of the organization’s service area (RR 4A.10).

·         How the member may voice a complaint (RR 4A.11).

·         How the member may appeal a decision that adversely affects coverage, benefits or his or her relationship with the organization (RR 4A.12).

·         How the organization evaluates new technology for inclusion as a covered benefit (RR 4A.13).

·         The organization’s routine use and disclosure of PHI [What a “routine consent” is and how it allows the organization to use information about the member.] (RR 5D.1).

·         Use of authorizations [The member’s right to approve the release of personal health information not covered by the “routine consent.”] (RR 5D.2).

·         Access to PHI [How the member may request access to his or her personal health information.] (RR 5D.3).

·         Internal protection of oral, written, and electronic PHI across the organization [How the organization protects member privacy in all settings.] (RR 5D.4).

·         Protection of information disclosed to plan sponsors or employers [The organization’s policy on sharing personal health information with employers.] (RR 5D.5).

·         The Explanation text in the NCQA Guidelines requires the organization to communicate its policies that address all confidentiality requirements covered in RR 6 Elements A and C and how they are implemented (RR 5D).

Items that must be communicated once since the prior survey:

·         The organization’s policy prohibiting financial incentives for utilization management decision-makers (UM 4E.1, UM 4E.2, and UM 4E.3).

Items with no specified frequency of communication (I recommend annual):

·         The toll-free number to contact staff regarding UM issues (UM 3A.5).

·         The availability of staff to answer questions about the UM process (UM 3A.6).

 

Member Communication Requirements for Health Plans

In my last blog I discussed communication requirements for members.  This blog addresses NCQA’s requirements for communicating with practitioners based on the 2009 Health Plan Standards.

In future blogs I’ll address member and practitioner communication requirements for managed behavioral health care organizations. 

Items that must be communicated annually:

·         Information about the quality improvement program including goals, processes, and outcomes as related to care and service (QI 2C.2).

Items that must be communicated on joining the network and annually thereafter:

·         The member rights and responsibilities statement (RR 2A.3 and RR 2A.4).

Items that must be communicated annually and whenever changes are made:

·         The organization’s pharmaceutical management procedures (UM 13F).

Initial distribution to all practitioners.  Distribution to all practitioners who subsequently join the network.  Distribution to all practitioners in a timely fashion following revisions:

·         Distribution of the organization’s adopted clinical practice guidelines to all appropriate practitioners (QI 9A.4).

Items that must be communicated once since the prior survey:

·         The organization’s policy prohibiting financial incentives for utilization management decision-makers (UM 4F.1, UM 4F.2, and UM 4F.3).

Items with no specified frequency of communication (I recommend annual):

·         The process to refer members to case management (QI 7B.6).

·         The process to refer members to disease management (QI 8C.6).

·         Information about disease management programs, including how to use the services and how the organization works with a practitioner’s patients in the program (QI 8H.1 and QI 8H.2).

·         A description of the organization’s treatment record policies including requirements for: confidentiality of treatment records, documentation standards, systems for organization of treatment records, standards for availability of treatment records at the practice site, and performance goals to assess the quality of medical record keeping.  A documented process describing treatment record policies and how the information is distributed to practitioners is also required (QI 12A.1, QI 12A.2, QI 12A.3, and QI 12A.4).

·         Information about the medical necessity criteria, including how to obtain or view a copy (UM 2 B.1).

·         The toll-free number to contact staff regarding UM issues (UM 3A.5).

·         The availability of staff to answer questions about the UM process (UM 3A.6).

·         The availability of, and process for, contacting an appropriate peer reviewer to discuss utilization management decisions (UM 7A.1 and UM 7A.2).

·         A description of the process to review information submitted to support a practitioner’s credentialing application, correct erroneous information and, upon request, to be informed of the status of the credentialing or recredentialing application.  A documented process describing the processes and how the information is distributed to practitioners is also required (CR 1B.1, CR 1B.2 and CR 1B.3).