Jun 06, 2023
MHR NCQA File Review

Word count: 624

Time to read: 3 minutes

Is your health plan managing both Medicare and Medicaid components for dual-eligible members? Questions often arise when deciding the UM file review universe at the time of an NCQA survey.

In this blog, we’ll review:

  • Pertinent points about files included in the universe, and
  • Which universe should a case be included when a service is reviewed under both Medicare and Medicaid criteria.

 First, why does this matter? 

  • File reviews are included in must-pass
  • Selecting the correct universe impacts non-behavioral, behavioral, and pharmacy files.
  • Dual-eligible members are included in UM denial file universes for both Medicare and Medicaid product lines.

Keep in mind the following:

  • Only cases reviewed for medical necessity are included in the denial file review universes.
  • Services that are always excluded under benefits should not be reviewed for medical necessity and, therefore, not included in the UM denial universe.
  • While Medicare and Medicaid cover many of the same services, Medicaid are state-based programs and may cover care that Medicare does not cover.

Here are some questions that MHR has encountered with its clients.

What happens when a case is reviewed under both Medicare and Medicaid medical necessity criteria?

  • The file must be included in both universes.

What happens when a case is reviewed under both Medicare and Medicaid and the service is denied under both for lack of medical necessity? 

  • The file must be included in both universes.

What if an item or service is never included or always excluded under benefits, but the health plan reviewed the item for medical necessity? 

  • If the plan reviewed the item under medical necessity criteria and was subsequently denied as “not a covered benefit,” the case is still excluded under the fie universe, assuming the item is always a benefit exclusion.

What if an item or service could be included as a benefit as long as it was determined to meet medical necessity criteria but was ultimately denied by the health plan?

  • The file must be included in the universe because it was reviewed for possible inclusion of a benefit.

How many file universes are there for dual-eligible members?

  • Medical necessity denials are reviewed by product line. Therefore, if you are bringing both Medicare and Medicaid product lines forward for an NCQA survey, there are file reviews for each product.

A case example that MHR encountered with a client illustrates this situation.

A member requested a wheelchair with a seat elevator. The wheelchair was reviewed by the health plan and approved under Medicare medical necessity criteria. The seat elevator was denied as a benefit exclusion.

Subsequently, the seat elevator was reviewed and denied under Medicaid medical necessity criteria.

Question:  What file review(s) would this case be included?

Answer:  Both Medicare and Medicaid.

How can MHR help?

File reviews for dual-eligible members can be complex.  The best way to know that you are compliant with NCQA policies is to conduct a mock file review of your dual-eligible members early in your look-back period. Having an objective review by MHR Consultants will give you the peace of mind that you are on the right track. 

Additionally, it is highly suggested to perform a trial run of file universes a few months prior to your NCQA survey and either organization staff and/or the consultant review for appropriate inclusion and exclusion of files in the universe. NCQA Surveyors appropriately excluding a file during file review can adversely affect the file outcome if the file denominator is significantly impacted.

Call to Action:  

  • Assess your organization’s procedures for:
    •  identifying dual-eligible members
    • deciding how cases are included in a file universe
  • Contact MHR for a mock file review and/or training:
  • Follow us on LinkedIn



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