Case Management (CM) Accreditation

Case Management (CM) Accreditation examines the organization’s delivery of case management services, such as care coordination and internal processes.

Organizations most commonly seeking CM Accreditation are:

• Accountable Care Organizations (ACO)
• Case Management organizations
• Hospitals that have members attributed to them by payers
• Population Health Program specialty organizations
• Physician organizations
• Third Party Administrators (TPAs)

The CM standards encompass traditional, transitional, and complex case management, as opposed to the case management standard in Health Plan Accreditation which is limited to standards for complex case management.   

CM organizations that are NCQA-Accredited Case Management are a benefit to health plans who delegate their case management to them because it reduces the health plan’s risk during file review.  Individual files chosen from the CM-accredited entity during a survey will receive automatic credit for the health plan.  Health plans may also be comforted knowing that the CM-accredited entity has processes that support high quality and understand NCQA more than non-accredited entities, thereby decreasing the need for extensive oversight.

Two MHR consultants who are Certified Case Managers and conduct Case Management and Long term Services and Supports CM (LTSS-CM) surveys for NCQA.

Credentialing (CR) Accreditation

Credentialing is the process by which organizations check the credentials and background of their licensed practitioners to help protect consumers and foster customer satisfaction.  Many organizations wonder whether to obtain CR accreditation or Credentialing Verification Organizations (CVO) certification. The value of having Credentialing Accreditation is that the credentialing process starts and stops within the organization – from the time the application is received until the Credentialing Committee makes a determination. This provides more control over the process and a faster trajectory of acceptance of the practitioner into the delegating organization’s network. Those entities that have practitioners in the organization’s administration, such as physician organizations, Accountable Care Organizations, hospital and health systems, and Physician-Hospital Organizations (PHOs) are more likely to choose CR over CVO.

Credentialing is one of the most frequently delegated standard sets that health plans delegate to other organizations. This can be seen on the NCQA Report Cards site (https:// ncqa.org/), where over 190 organizations are listed as having Credentialing Accreditation.

Organizations most commonly seeking Credentialing Accreditation are:

• Accountable Care Organizations
• Health networks and systems
• Hospitals
• National or regional health plans
• Physician organizations
• Specialty organizations

Credentialing and recredentialing file reviews and Information Integrity are must-pass elements for Health Plan Accreditation. Therefore, health plans are at greater risk because a delegate’s credentialing files are included in the universe of files subject to file review by NCQA during the health plan’s accreditation survey.

Organizations pursuing Credentialing Accreditation are at risk because their file review conducted by NCQA is also a must-pass element.

The level of oversight from delegating organizations can be decreased for entities with Credentialing Accreditation. Likewise, entities with Credentialing Accreditation provide less risk to health plans that delegate credentialing to them.

Health Equity Accreditation and Health Equity Accreditation Plus

NCQA has been a leader in promoting equitable care with its original program, Multicultural Health Care (MHC) Distinction. NCQA’s continuing journey in promoting equitable care has evolved into two accreditations.  Health Equity Accreditation (HEA) focuses on developing foundational processes, collecting data, and identifying opportunities for improvement. Health Equity Accreditation (HEA) Plus expands the requirements for HEA and branches out to community needs, risk factors, and community organization support.  Both HEA and HEA Plus are three-year accreditation programs.

Organizations most commonly seeking HEA are:

• Health plans
• Health systems
• Managed Care Organizations (MCO)
• Accountable Care Organizations
• Managed Behavioral Healthcare Organizations (MBHO)
• Wellness and population health organizations
• Other organizations

Organizations seeking HEA Plus are the same as those seeking HEA but typically have more years of experience, furthering health equity. HEA Plus sits on top of HEA, so organizations cannot choose HEA Plus without HEA. Organizations may pursue both concurrently, although MHR does not recommend this unless there is a strong presence of conducting the HEA Plus activities prior to the beginning of HEA preparation.

One area that is most problematic for every organization with which MHR has worked is that of data.

Data is needed on individuals to identify:

• race/ethnicity
• language
• gender identity
• sexual orientation

After data is collected, it is used to:

• Address disparities
• Monitor and assess services
• Measure Culturally and Linguistically Appropriate Services (CLAS) and disparities

Organizations benefit from MHR having four consultants with multiple years of experience surveying organizations for MHC Distinction and now with HEA.  Their expertise is highly valuable in advising organizations and coaching staff on:

• Assimilating their data from multiple sources, including where the data is captured and collected
• Determining how best to use the data
• Structuring programs that are both meaningful and reduce health disparities of their members
• Implementing programs
• Holding cross-functional and departmental discussions such as with IT, the data warehouse staff, and HEDIS analysts

Depending upon the knowledge and skill levels of the organization’s staff, management, and executive team who are pursuing HEA, training sessions that may be helpful are:

• Analysis
• Health Equity

Health Information Product (HIP) Certification

NCQA’s HIP Certification is a way for companies to distinguish themselves when providing services to health plans and Managed Behavioral Health Organizations. Certification is offered for:

• Health Information Line
• Pharmacy Benefit Information
• Physician and Hospital Directory
• Support for Healthy Living

As can be seen on the NCQA Report Card site (https://ncqa.org), HIP Certification is not a highly utilized product.  However, it is highly valuable for health plans and MBHOs who use their services since they can receive credit on their related standards during their accreditation surveys.

All MHR consultants have extensive experience preparing organizations for all four HIP Certifications.

Health Plan Accreditation (HPA) is the original NCQA accreditation product from which all others have derived and grown to support this accreditation. NCQA’s Report Cards site lists over 1,200 plans that have NCQA accreditation, representing all US states and territories. MHR’s consultants have significant expertise in HPA for all types of Plans and Products, including: 

NCQA offers a glide path to accreditation, starting with an Interim Survey. Interim is a subset of the entire Health Plan standards without more rigorous look-back periods for meeting the requirements. Interim accreditation helps organizations meet state regulations that require accreditation, typically for the Medicaid line of business. Interim also allows health plans new to NCQA accreditation to slowly ramp up to achieving HPA. Health plans can only be surveyed at the Interim level once. If health plans do not pass their Interim survey, they can re-apply in a year, but only at the next level, which is the First Survey.

First Surveys occur 18 months after the Interim survey or organizations may choose to enter the accreditation path with a First Survey. With the First Survey, all the Health Plan standards except for remeasurement must be met, with a look-back period of six months. First Surveys are a significant step, as health plans must have documentation for all standards and implement outcomes measurement and analysis beyond HEDIS measures. However, HEDIS is not required to be submitted until the year after the Interim or First Survey accreditation status is effective.

Note that First Surveys can be the second step in HPA or could be the initial foray into accreditation; NCQA allows either. MHR has found through consulting and conducting NCQA surveys that some plans have major struggles in reaching First Survey requirements, particularly if they have not systematized processes or have fallen behind on requirements needed for the six-month lookback period.

Many health plans find that Interim Survey preparation does help staff get acclimated to NCQA requirements and become more purposeful and formalized before meeting the First Survey requirements.

Last on the glide path towards HPA is the Renewal Survey, which is scheduled three years after the prior First Survey. For the Renewal Survey, the requirements are more rigorous. Documented processes must be in place for the entire 24-month look-back period, many materials must be in place throughout the look-back period, and annual reports must have two annual requirements separated by 12 –14 months. This means that processes must be systematized to meet the standard's intent and occur at regular intervals. Denial, appeal, and case management files have a one-year look-back period. However, the credentialing and recredentialing process is ongoing and needs to be constantly monitored by health plans to assure that these must-pass requirements are met even with staff turnover.

Organizations can incur many challenges on the glide path towards HPA.  MHR’s expert consultants work with you proactively to help you achieve success and help prevent corrective action plans (CAPs).  See more detail on How We Work.

But it doesn’t stop there. MHR recognizes that other challenges arise, such as losing seasoned staff, gaining new team members without experience in NCQA, and lack of support by individuals, executives, or key departments.  Any of these challenges can result in missed requirements, not meeting the look-back periods, and low morale.

MHR consultants have worked with many organizations new to accreditation. They know that many do not have sufficient documentation when the consulting period begins but must develop the documentation as they go. However, MHR’s philosophy is to have clients build their own documentation and then have MHR review those documents; at times, clients do not have the skills or experience to develop them independently. Occasionally, our consultants are asked to model the necessary documentation once to replicate it for future documentation needs.

To help organizations align the format and consistency of their qualitative and quantitative analyses throughout their organization, MHR offers for purchase templates to write their analysis documents. These templates are particularly helpful in areas responsible for quality improvement, network management, credentialing, utilization management, case management, population health management, and member experience.

Lastly, organizations may purchase training sessions, which are presented by MHR consultants who have hands-on experience and their fingers on the pulse with NCQA updates. 

Depending upon the knowledge and skill levels of the organization’s staff, management, and executive team who are pursuing HPA, some training sessions that may be helpful are:

• Analysis
• Annual Standard Changes
• Appeals
• Basics of NCQA Accreditation
• Complex Case Management
• Delegation
• Denials
• Health Equity
• Member Experience
• Network Management

Managed Behavioral Health Organizations (MBHO) that are accredited demonstrate their excellence to health plans, employers, regulators, and consumers.  Organizations seeking this accreditation must meet the requirements of 41 standards similar to those of Health Plan Accreditation but specific to behavioral health.  Important within the standards are complex case management and data exchanges between primary care and behavioral healthcare providers.

Organizations seeking MBHO Accreditation are:

• Organizations specializing in behavioral healthcare

MHR is well-prepared to partner with MBHOs seeking MBHO Accreditation.  Most consultants have experience in the behavioral health managed care setting or have behavioral health care experience and understand the nuances and differences. Some MHR consultants also conduct MBHO surveys on behalf of NCQA, so they are very knowledgeable of the requirements. Knowledge and experience are critical when hiring a consulting firm.

There are over 30 NCQA-Accredited MBHOs as seen on NCQA’s Report Cards site. Depending upon the knowledge and skill levels of the organization’s staff, management, and executive team who are pursuing MBHO Accreditation, some training sessions that may be helpful are:

• Analysis
• Appeals
• Complex Case Management
• Delegation
• Denials
• Health Equity
• Member Experience
• Network Management

Model of Care (MOC) Development and Review

Centers for Medicare & Medicaid Services (CMS) requires that Special Needs Plans have in place an evidenced-based model of care (MOC). CMS requires that NCQA approves the MOC.  NCQA trains the surveyors selected for MOC review with CMS guidance on calendar year changes.

MOCs are typically submitted at the timeframe designated by CMS for the following calendar year, so organizations must plan well in advance to develop and submit the MOC. Four major sections and several sub-sections must be completed, and the scoring is based on meeting a specific number of points for each area.

Organizations seeking MOC Development and Review are:

• Special Needs Plans (SNPs)
• Health Plans

MHR works with organizations to assist them in developing a compliant MOC. The greatest area of struggle by clients is the lack of detail and specifics and focusing only on processes and not outcomes.

Three of the MHR consultants conduct MOC surveys, and one of the three, on behalf of NCQA, is an executive reviewer for evaluating other surveyors’ work.  Our consultants who work with MHR clients do not also work with NCQA on client reviews to avoid a conflict of interest.

MHR clients generally score 99 – 100% on their submitted MOCs when they have worked closely with the consultant and submitted the final drafts to MHR.

NCQA’s Population Health Program (PHP) is designed for organizations providing specialty services to specific populations based on a quality improvement framework. In 2019, NCQA transitioned the Disease Management (DM) standards to PHP standards, following the industry trend.

Organizations most commonly seeking PHP Accreditation are:

• Organizations providing targeted condition care
• Standalone organizations specializing in a single disease entity
• Physician organizations providing care for specific diseases

Over 30 organizations currently have PHP accreditation.

MHR consultants train staff on the standards and expectations, transferring knowledge to help them be successful on an ongoing basis. Since all the organizations use a case management approach for the highest population segment, Case Management Accreditation is a great fit for PHP-accredited organizations, which is reflected in that almost half of the PHP organizations also have CM Accreditation.

Depending upon the knowledge and skill levels of the organization’s staff, management, and executive team who are pursuing PHP Accreditation, training sessions that may be helpful are:

• Complex Case Management
• Health Equity

Population Health Management Prevalidation Certification

Population Health Management (PHM) Prevalidation certification is for organizations with health information technology (IT) solutions, including data integration, population assessment, segmentation, and case management systems. 

Organizations seeking PHM Prevalidation Certification are:

• Health IT vendors

Health IT vendors who seek this certification demonstrate their commitment to product functionality that supports or meets NCQA’s related standards. PHM Prevalidation supports four different accreditation programs: Population Health Management, Case Management, Managed Behavioral Health Organizations, and Health Plan Accreditation. Organizations using health IT solutions with PHM Prevalidation Certification can earn automatic credit on specific standards for their NCQA surveys, easing the organization’s administrative burden for supporting documentation.

There are currently 16 organizations that hold this certification.  MHR helps organizations meet the standards for PHM Prevalidation. Only internal NCQA staff conduct the final review for this product.

Although there is no specific training for PHM Prevalidation, MHR’s training session on Population Health Management may be helpful to gain a broader perspective. 

Utilization Management (UM) Accreditation

UM Accreditation examines whether organizations make healthcare services decisions using objective, evidence-based criteria. UM is the most rules-based set of standards outside of Credentialing, and the number of pages of the UM standards is twice as long as Credentialing. UM standards are particularly challenging in that they include must-pass elements on file reviews for medical, behavioral health, pharmacy, and appeal files; Information Integrity for denials and appeals; and are often delegated by health plans.

Organizations most commonly seeking UM accreditation are:

• Accountable Care Organizations (ACO)
• Case Management organizations
• Hospitals that have members attributed to them by payers
• Population Health Program specialty organizations
• Pharmacy Benefit Managers (PBMs)
• Physician organizations
• Third Party Administrators (TPAs)

Organizations having NCQA UM Accreditation are advantageous to health plans because health plans are at risk of their accreditation status when they delegate UM to other organizations. Files from delegates are included in the health plan’s universe of files that can be selected for their Health Plan Accreditation survey.  When files from an NCQA-Accredited UM organization allow the health plan to receive auto-credit for those files, delegating to a non-accredited organization does not allow for such auto-credit. A high volume of denials and appeals from a non-accredited organization could cause health plans to be placed on a corrective action plan (CAP) or can even cause a denial of their Health Plan Accreditation with just three or more non-compliant files.

MHR consultants are highly skilled in UM. They prepare health plans for accreditation and keep current on new requirements. Most of the MHR consultants are also NCQA surveyors for UM, so they can accurately interpret requirements and the nuances that NCQA expects. MHR consultants help the organization’s staff to understand the interpretation through side-by-side coaching.

Depending upon the knowledge and skill levels of the organization’s staff, management, and executive team who are pursuing UM Accreditation, additional training sessions that may be helpful are:

• Delegation
• Utilization Management Accreditation

Wellness and Health Promotion (WHP) Accreditation/Certification

NCQA’s Wellness and Health Promotion (WHP) Accreditation/Certification evaluates entities’ organizational processes and program effectiveness in engaging individuals to improve their health.  WHP Accreditation/Certification benefits employers, consumers, regulators, and health plans by knowing that the programs they have purchased use best practices and evidence-based methods to help improve health outcomes.  WHP also provides NCQA-accredited clients and MBHOs with automatic credit on relevant standards for their delegated wellness services.

Organizations seeking WHP accreditation/certification are:

• Organizations or vendors providing wellness programs to employers, consumers, regulators, and health plans

The NCQA WHP standards encompass Client Engagement, Data Exchange, Privacy, Engaging the Population, Health Appraisal, Identification and Targeting, Self-Management Tools, Health Coaching, Rights and Responsibilities, Measuring Effectiveness (Accreditation or Certification), Incentive Management, and Reporting Performance.

While NCQA WHP Accreditation evaluates full-service wellness programs, WHP Certification is for programs that are more limited in scope, including:

• Health Appraisal
• Self-Management Tools
• Health Coaching

NCQA-accredited health plans and MBHOs benefit from organizations and vendors that are WHP Certified by receiving automatic credit for relevant standards for Health Appraisal and Self-Management Tools. Certification receives two-year certification and Accreditation lasts for three years.

MHR consultants prepare organizations and vendors to meet the requirements for WHP and survey this product on behalf of NCQA.

Templates, Tools, and Training Products

MHR has spent hundreds of hours developing various templates, tools, and training products to support different accreditations. Some templates and tools are free to clients, but most are available for purchasing a license for use by the organization that purchased them. Additional training sessions are available to our clients for purchase.

Because analysis is the more challenging of reports due to the requirement for quantitative and qualitative analysis of the findings, the template on Analysis provides detailed guidance, prompting the writer for the required information.

The other major challenge for managing accreditation is delegation. MHR has a suite of tools on Delegation to guide organizations and methods of tracking oversight and compliance.

Additional training sessions available to our MHR clients are listed here.  For more information on these sessions, see our section on Training. 

• Analysis
• Annual Standard Changes
• Appeals
• Basics of NCQA Accreditation
• Case Management (CM)
• Credentialing
• Credentials Verification Organization (CVO)
• Delegation
• Denials
• Health Equity (HE)
• Health Information Products (HIP)
• Health Plan (HPA)
• LTSS Distinction or CM-LTSS (LTSS)
• Managed Behavioral Healthcare Organization (MBHO)
• Member Experience (ME)
• Network Management (NM)
• Population Health Management (PHM)
• Population Health Program (PHP)
• Quality Management and Improvement (QI)
• System Controls
• Utilization Management (UM)
• Wellness and Health Promotion (WHP)