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).