Are You Sending NCQA Denial Notices to the Right Person?

Estimated time to read: 3 minutes

Denial notices that arrive too late—or never arrive at all—can cause confusion and frustration for providers, practitioners, and patients. MHR frequently sees errors during file reviews regarding who should receive the denial notice.

In this blog, we:

• Clarify the difference between a practitioner and a provider
• Review the NCQA Utilization Management (UM) standards
• Outline what to do if you’re unsure where to send the denial notice

Don’t Gloss Over the Glossary

It starts with knowing who’s who. The NCQA Glossary defines these roles clearly, and using the wrong term can lead to miscommunications.

Practitioner: A licensed or certified professional who provides medical care or behavioral healthcare services
Licensed Independent Practitioner: An individual permitted by law to provide services without direction or supervision, within the scope of the individual’s licensure or certification and in accordance with individually granted clinical privileges
Provider: An institution or organization that provides services (e.g., hospital, residential treatment center, home health agency, rehabilitation facility, pharmacy).

NCQA Glossary

NCQA’s glossary is more than a reference—it’s part of the standards.

Who Gets the Denial Notice?

If the practitioner didn’t get the denial notice, it might be because they wrongly weren’t the intended recipient.

Here’s what the UM standards say about who should receive denial notices:

• UM 7, Element B – Nonbehavioral Healthcare: Send to both the member and the treating practitioner
• UM 7, Element E – Behavioral Healthcare: Send to both the member and the treating practitioner
• UM 7, Element H – Pharmacy: Send to both the member and the prescribing practitioner

No Treating Practitioner Listed? Here’s What to Do

NCQA provides direction when the treating practitioner’s name isn’t available. See Related Information for UM 5 Elements A, B, and C.

Reasons the name might be missing:

• The request didn’t include it
• The request came from a provider (as listed below), not an individual practitioner

Common examples of requests from a provider without a named practitioner, but with prior authorization requirements that we have seen frequently include:

• Durable medical equipment (DME)
• Residential or behavioral health treatment centers
• Freestanding MRI centers
• Sleep labs

When the practitioner’s name is unknown to the health plan the standards require that you:

• Call the facility or ask the patient, family, or representative
• Document every attempt to identify the practitioner in your UM system.
• Send the practitioner notice to the provider, marked ‘Attention to:’ and include the practitioner’s role (e.g., attending, admitting, ordering).

For urgent concurrent decisions:

• Notify the hospital’s Utilization Review (UR) department. Don’t delay the process by searching for the treating practitioner. NCQA assumes that the UR team will follow up internally.

Scoring Implications

Even if the denial notice is otherwise accurate, if it’s not sent to the correct practitioner, your organization could lose points in file review for multiple elements in UM 5 and 7.

 Key Points:

• Treat the NCQA Glossary as part of the standards
• Review the Glossary annually and with each NCQA update
• Establish a process to identify treating practitioners when missing or unknown
• Always document outreach efforts in your UM system
• Regularly audit UM files to confirm that denial notices are going to the correct recipients

MHR Tools and Support

Denial notices going to the wrong party is one of the most common and avoidable compliance pitfalls. Discover how MHR can enhance your UM denial and appeal processes.

Check out our Products and Services page for resources on UM training and file reviews.

For questions about which resources can best assist your organization, please contact your MHR consultant or email us at [email protected].

MHR ensures quality and accuracy in every blog.

This article includes insights from Erin Kafieh, RN.  Learn more about MHR’s independent consultants at managedhealthcareresources.com/AboutOurConsultants