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).