NCQA Corrections, Clarifications and Policy Changes to the 2012 DM Standards and Guidelines March 26, 2012

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1 This document includes the corrections, clarifications and policy changes to the 2012 DM Standards and Guidelines. NCQA has identified the appropriate page number in the printed publication and the standard and head/subhead for each update. s have been incorporated into the Interactive Survey System (ISS). NCQA operational definitions for correction, clarification and policy changes are as follows: A correction (CO) is a change made to rectify an error in the Standards and Guidelines A clarification (CL) is additional information that explains an existing requirement A policy change (PC) is a modification of an existing requirement An organization undergoing a survey under the 2012 DM standards and guidelines must implement corrections and policy changes within 90 calendar days of the ISS release date, unless otherwise specified. The 90-calendar-day advance notice does not apply to clarifications or FAQs because they are not changes to existing requirements. 1 Policy Overview Remove the first bullet which reads: Required performance measures reporting for organizations seeking accreditation for diabetes, heart failure, ischemic vascular disease (IVD), chronic obstructive pulmonary disease (COPD) and asthma programs 7 Policy Overview Performance Measures 25 Policy Policies and Procedures 25 Policy Policies and Procedures AWPR Revise the first sentence to read: Organizations seeking AWPR for any of the following programs must submit NCQA DM performance measures specified for the program. Add the following subhead and text immediately preceding ""AWPR Status" subhead: DM Performance Measure Reporting Organizations seeking NCQA Accreditation may voluntarily submit DM Performance Measure results for reporting year NCQA reserves the right to require of measures for all accredited organizations, including those without AWPR status. If is required in the future, organizations will be notified at least 90 calendar days prior to the date. Organizations that meet minimum thresholds for measure and minimum scoring thresholds for standards are granted AWPR status. Organizations applying for this status must: Submit audited DM Performance measure results with their completed Survey Tool. Annually resubmit audited measure results on the annual measure date to retain AWPR status An organization that does not meet minimum thresholds for submitting audited measures receives Accredited status. The organization retains this status until its next scheduled Full Survey or until its status changes after its annual re of DM Performance Measures. Revise the second paragraph to read: Accredited organizations may annually submit audited DM performance measures for all Key = CO Correction, CL Clarification, PC Policy Change 1

2 Status programs with eligible measures. Organizations with programs undergoing an Accreditation Survey for the first time after July 1, 2010 (whether an Initial Survey or a Renewal Survey), with the survey starting between January 1 and April 30, should report DM performance measures using the specifications effective as of July 1 of the calendar year before their survey. Organizations with surveys starting on or after May 1 through December 31 should report DM performance measures using the specifications effective as of July 1 of the calendar year of their survey. 26 Policy Policies and Procedures How Failing to Submit Performance Measures Affects Accreditation Status 27 Policy Policies and Procedures Annual Re of Results 27 Policy Policies and Procedures Annual Re of Results 27 Policy Policies and Procedures Delete the first paragraph which reads: Organizations seeking NCQA DM Accreditation and NCQA Accredited disease management organizations surveyed on or after July 1, 2010, must submit eligible DM performance measures on or before the June 30 deadline. Eligible DM performance measures include any measure for conditions listed under PM 1 PM 5 that an organization is responsible for managing. If the organization does not submit the required performance measures, NCQA classifies eligible measures as Not Reported and scores all measures against the scoring thresholds. Revise the first sentence of the first paragraph to read: Organizations that achieve and wish to retain AWPR status must resubmit measure results annually by the required date for scoring of the applicable PM elements. Add as the last sentence of the third paragraph: NCQA will remove conditions from the organization s listed Measures Reported on the DM Accreditation and Certification Report Card, for which the 80% threshold is not met ( Add the following subhead and text immediately preceding the "Accredited or Certified DM Organizations and Other NCQA Accredited Programs" subhead: Option to Upgrade to AWPR Status Organizations that receive accredited status under NCQA s 2010 or 2012 standards and guidelines for accreditation in DM may submit DM performance measure results for an upgrade to AWPR status. To be considered for an upgrade, an organization must complete an application for the change in status, execute an addendum to its Agreement, pay an upgrade fee and submit measure results by the annual reporting date. An organization that meets the minimum threshold for submitting audited measures is upgraded to AWPR. The organization retains this status until its next scheduled Full Survey or until its status changes after its annual re of DM performance measures. The organization must submit DM performance measures results annually until its updated AWPR status expires Key = CO Correction, CL Clarification, PC Policy Change 2

3 (i.e., three years after the initial NCQA Accreditation decision). The organization must receive at least 80% on the applicable PM standard to achieve AWPR status. 28 Policy Policies and Procedures Expiration of Accreditation or Certification Status 33 Policy Policies and Procedures Submit measure results Add the following as the last sentence. The length of time a status has lapsed is measured from the date of expiration or withdrawal of the prior status until the scheduled start date of the next survey. Revise the language to read: All organizations electing to submit DM performance measures must submit audited results using the DM reporting tool, after it has been reviewed and locked by the auditor. Purchasers of the Disease Management Technical Specifications will receive an with the date when the DM reporting tool will be released. The process for submitting performance measures depends on whether it is the first time the organization is submitting measures, or if the organization submitted measures during its last survey. An organization submitting performance measures for the first time attaches the audited DM performance measure reporting tool to its ISS Survey Tool under PM 1, A, and submits it at the time of its survey. An organization that submitted performance measures during its last survey should send the audited DM performance measure reporting tool to surveysupport@ncqa.org on or before the date. Any organization that has applied for an upgrade from Accredited to AWPR should also submit its audited DM performance measure reporting tool to surveysupport@ncqa.org on or before the date. CL 3/26/12 56 EB 3, A, Factor 2 Explanation Designated physician and behavioral health practitioner Replace the last sentence of the first paragraph with: The behavioral healthcare practitioner must be a behavioral healthcare physician (i.e. MD or DO) or a doctoral-level behavioral healthcare practitioner (i.e. PsyD or PhD) with behavioral healthcare training. 99 PR 1, A, Factor 3 Exceptions Revise the second paragraph to read: Factors 3 and 4 are NA for organizations that are seeking program design certification and do not develop materials for practitioners or direct materials toward practitioners. 127 MQ 1, B Explanation Identifying clinical issues Revise the second sentence to read: The first measure of clinical quality is assessed in A; a second measure of clinical quality is assessed in this element. Key = CO Correction, CL Clarification, PC Policy Change 3

4 133 MQ 1, E stem Revise the stem and factors to read: The organization demonstrates either significant improvement or meaningful improvement in: 1. The first clinical quality measure 2. The second clinical quality measure. 165 OP 1, A Explanation Staffing needs and licensure 172 OP 2, A Explanation Licensure Remove the last sentence of the second paragraph and the two subsequent paragraphs which read: Licensure must be verified in all states where staff provide direct care to members. Direct care means that staff have physical contact with a patient (e.g., via office visits, home visits). If the organization provides telephone care or telemedicine services, the organization must determine licensing requirements for provision of these services in states where members reside and must license staff accordingly. Replace the second sentence with: The organization must determine licensure requirements in states where DM services are provided. 214, 216, 218, 220, PM 1-5, A Explanation Measure Add as the last sentence: The DM Technical Specifications are available for purchase on our Web site, or by calling NCQA Customer Support at Previously Posted s Head/Subhead 46 EB 1, A Explanation Remove the last sentence of the first paragraph, which reads: There must be evidence that the organization conducts a review at least every two years. 98 PR 1, A Explanation Written program description 102 PR 3, A Explanation Documentation Remove the second paragraph, which reads: The practitioner may be the physician or nurse practitioner who is providing primary care and care coordination services for the patient. The practitioner may also be a subspecialist (e.g., endocrinologist, oncologist) who provides primary support and care for the patient. Remove the fourth paragraph, which reads: The organization may locate information on its Web site and tell practitioners that the Type of CO 11/21/11 Key = CO Correction, CL Clarification, PC Policy Change 4

5 Head/Subhead information is available and where it can be located. 103 PR 3, A Explanation Distribution of practitioner program information Change references from patients to practitioners so the text reads: Distribution of practitioner program information The organization may communicate information through the following methods: In writing by mail, fax or On the Web, if it notifies practitioners that the information is available. If the organization communicates by fax or with practitioners who have fax or access, it must use an alternate method for practitioners without fax or access. If the organization uses a Web site to distribute information, it may use fax or to notify practitioners that the information is available on the Web site. 214 PM 1, A Explanation Revise the first sentence in the first paragraph to read: Organizations coming forward for DM accreditation for diabetes programs may submit the Management of People With Diabetes measure/indicators. 214 PM 1, A Explanation Measure 214 PM 1, A Explanation Annual re All organizations with AWPR status must annually resubmit measure results on the date specified by NCQA to retain their status. 216 PM 2, A Explanation Revise the first sentence of the first paragraph to read: Organizations coming forward for DM accreditation for heart failure programs may submit the Management of People With Heart Failure measure/indicators. 216 PM 2, A Explanation Measure 216 PM 2, A Explanation Annual re Revise the third bullet to read: All organizations with AWPR status must annually resubmit measure results on the date specified by NCQA to retain their status. 218 PM 3, A Explanation Revise the first sentence of the first paragraph to read: Organizations coming forward for DM accreditation for programs focusing on ischemic vascular diseases (IVD) such as coronary artery disease (CAD), stroke and peripheral artery disease (PAD) may submit the Management of People With Ischemic Vascular Disease measures/indicators. 218 PM 3, A Explanation Measure Type of CO 11/21/11 Key = CO Correction, CL Clarification, PC Policy Change 5

6 Head/Subhead 218 PM 3, A Explanation Annual All organizations with AWPR status must annually resubmit measure results on the date specified by NCQA to retain AWPR status. 220 PM 4, A Explanation Revise the first sentence of the first paragraph to read: Organizations coming forward for DM accreditation for programs focusing on COPD may submit the Management of People With COPD measures/indicators. 220 PM 4, A Explanation Measure 220 PM 4, A Explanation Annual re All organizations with AWPR status must annually resubmit measure results on the date specified by NCQA to retain their status. 222 PM 5, A Explanation Revise the first sentence of the first paragraph to read: Organizations coming forward for DM accreditation for programs focusing on asthma may submit the Management of People With Asthma measures/indicators. 222 PM 5, A Explanation Measure 222 PM 5, A Explanation Annual re All organizations with AWPR must annually resubmit measure results on the date specified by NCQA to retain their status. Type of Key = CO Correction, CL Clarification, PC Policy Change 6