The NCQA 2012 standards go live on July 1, 2012. Are you ready?
I thought I’d present an overview of some of the notable changes from the 2011 standards for Health Plans and Managed Behavioral Healthcare Organizations. The list below focuses on Utilization Management.
The definition of medical necessity now includes decisions about pre-existing conditions when the member has creditable coverage and the organization has a policy to deny pre-existing care or services.
Written notification to the member and practitioner include a statement that an expedited external review can occur concurrently with the internal appeals process.
The organization must provide continued coverage of an ongoing course of treatment pending the outcome of an internal appeal.
There must be policies and procedures for providing notices of the appeals process in a culturally and linguistically appropriate manner.
The appeals file review evaluates whether or not there was an appropriate response to the substance of the appeal.
These are not the only changes to UM but they are the ones that I think are most significant. Stay tuned for part 2, where I will discuss changes to the other categories of
standards.
