Guidelines for a Successful OC Survey

Guidelines for a Successful OC Survey 2007 Standards Welcome to the NCQA Organization Certification (OC) survey process. The guidelines and resources contained in this appendix will help you prepare for your organization s survey and maximize the efficiency of your preparation time. OC Survey Process Readiness evaluation NCQA survey NCQA now uses a Web-based Survey Tool for accreditation surveys. The Survey Tool allows organizations to perform a readiness evaluation at their own pace before submitting data to NCQA. You can assess your programs and operations and estimate your performance against NCQA standards. During this stage, NCQA does not view your information. The NCQA survey process begins with the submission of the Survey Tool and ends with the onsite survey. When you apply for an NCQA Certification survey, a date is set for the electronic submission of the Survey Tool and a subsequent onsite survey. The survey is separated into two stages: The offsite review of your electronically submitted materials and readiness evaluation and The onsite review of your organization s credentialing, denial, appeal and delegation oversight. For separate CR Certification or UM Certification, NCQA conducts the on-site review within one-day. If your organization is seeking certification in both CR and UM, the on-site review is conducted within two-days. At approximately six months prior to submission of the Survey Tool, you will be contacted by an assigned Accreditation Survey Coordinator (ASC), who will assist you during the survey process. If you have specific questions about your preparation before your ASC is assigned, contact Customer Service at 888-275-7585, 8:30 a.m. 5:30 p.m. Eastern Time or via e-mail at customersupport@ncqa.org. URAC Accreditation NCQA accepts URAC UM Accreditation as fully meeting comparable standards in the UM Certification program. An organization that holds Full accreditation from URAC at the time of its NCQA Certification survey under the 2007 standards is not reviewed against the requirements of certain standards at the time of the survey. An organization must document its URAC Accreditation and attach a copy of the URAC certificate in the organization background section of the Survey 2007 Guidelines for Successful OC Survey 1

Tool. The URAC certificate should also be included with the application. 2007 Guidelines for Successful OC Survey 2

Preparing for Readiness Evaluation 1. To facilitate the process, you may find it helpful to keep documents that you link to the Survey Tool in a single directory shared by all your users. This will facilitate multiple users working on the Survey Tool. You can modify, move or rename a linked document since it is not final until you submit it to NCQA for survey. If you move or rename documents, be sure to update the links in the Survey Tool before your final submission. 2. The Document Library includes a list of all documents linked to your Survey Tool. From here, you can link, unlink or edit documents for any element. Refer to the instructions under the Help tab for detailed information. You can also add documents to the library without linking them to a specific element. This feature allows you to "load" your documents so that they are available in a list of "previously linked" documents that you can access when you need to link a document to an element during your readiness evaluation. NCQA limits the types of documents you may send. (See the list of Recommended Supporting Documents at the end of these guidelines.) NCQA encourages you to submit only documents, pages or sections necessary to demonstrate how your organization meets the standards. Completing the Standards and Guidelines and Survey Tool Print out and use the instructions in the Survey Tool, which you can access by clicking the Help button on the Navigation Bar on the opening screen. The Standards and Guidelines and Survey Tool instructions appear on the next screen. They provide all the information necessary to successfully navigate and complete the tool and complete your readiness evaluation. As you assess your compliance with each element, be sure to: 1. Preload your document library with essential documents that demonstrate compliance against the standards. 2. Evaluate each element and attach the document that demonstrates compliance by linking it to an existing library document or, if necessary, attach a new document by clicking the Link a New Document button. 3. After entering a data element, save it before moving on by clicking the Save button or the Next button. 4. Other than file review and delegation oversight elements, each element must have supporting documentation. However, supporting documentation should be limited to no more than three documents per element. (See the list of Recommended Supporting Documents at the end of these guidelines.) File review and delegation oversight elements will be assessed during the onsite survey. These elements should be marked NA at the time of submission. Other elements that require review of minutes or confidential information (e.g., QI 2A, QI 2B, CR 2) may also be reviewed on site. Clearly document elements in which automatic credit is given for delegating to an NCQA-Accredited or NCQA-Certified entity. In order for the survey team to grant automatic credit, the organization should attach a document 2007 Guidelines for Successful OC Survey 3

Preparing for File Review that clearly delineates the delegate s responsibilities. 5. For each supporting document listed, you must: identify the page number containing the information that supports the element, as specified in the Survey Tool. attach only pages and sections necessary to demonstrate how your organization meets the standards, as well as any cover page that identifies the document and, if applicable, provides its date. If you reference a document multiple times, you may place the entire document in the document library and reference different pages and paragraphs throughout your assessment. 6. If you wish to stop using the Survey Tool, click on the Log Out button located on the Navigation Bar. You should log out even if you only plan a short break. This will properly notify the system that you are done with your session. If you do not log out, the Survey Tool will time-out after 30 minutes of inactivity. NCQA surveyors review up to 30 files for each file review element. You will prepare a sample of 40 files, allowing for a 10-file oversample. 1. Download the instructions for each file review by retrieving them from the Appendix section of the survey tool. The Table of Contents tab contains hyperlinks to the remaining tabs. Clicking the name of the worksheet on this tab takes you directly to the worksheet. You can also access each worksheet by clicking the tabs along the bottom of the screen. Use the right arrow key to identify documents contained in the workbook. 2. Enter the requested data as directed by the file submission instructions. Medical necessity certifications and appeals: Information concerning the estimated number of appeals and denials is due to NCQA four weeks prior to submission. Selected dates and number of denials and appeals are due at submission. CR: Information in an Excel format is due to NCQA at submission. 3. Each file review element contains file review worksheets and instructions that the surveyors will use to complete the file review elements during the onsite survey process. The worksheets are found under the Supplemental Worksheet button located at the bottom of the applicable file review elements. There is one combined workbook for utilization management (UM) denial, appeal and emergency room (ER) denial file reviews, located under each UM file review element (e.g., UM 4C, 4D, 5A). There is one combined workbook for the credentialing and recredentialing (CR) file review, located under each CR file review element (e.g., CR 3A, 3B, 4A). You can utilize these worksheets to perform your own internal audits of your files. 2007 Guidelines for Successful OC Survey 4

Submitting the Survey Tool: Start of the Offsite Survey Process Upon completion of your readiness evaluation, you will submit the Survey Tool on or before the date assigned for submission. Be aware that: after you submit the Survey Tool, you will not be able to change data in the Survey Tool or submit additional materials. after you have submitted the Survey Tool, the survey team (consisting of a clinical surveyor and an administrative surveyor), will perform the majority of its assessment off site. approximately two weeks after you submit the Survey Tool, the ASC will communicate with your organization s designated contact to request clarification of any surveyor-identified issues. Submit requested material electronically to the ASC as quickly as possible. The ASC will attach the material to the Survey Tool. About five weeks after you submit the Survey Tool, there will be a conference call with members of the organization s staff, the survey team and the ASC. NCQA will provide you with an agenda approximately 24-48 hours prior to the call. The purpose is to clarify issues identified by the survey team. Scoring or results of the ongoing offsite survey will not be discussed. Following the conference call that is held between the team and the organization, the organization will have 3 business days to send additional clarifying documentation. At that point, the offsite portion of your NCQA survey has concluded and no additional clarifying documentation will be accepted at the time of the onsite survey (with the exception of documents that cannot be supplied electronically or documents that are confidential). Communication During the Offsite Survey After you submit the Survey Tool, the ASC will be the single contact for your organization. During the first five weeks of the survey process, you can clarify elements with the ASC, though this process is not intended to open the survey for additional new materials and your organization should not attempt to contact the surveyors. If questions or a need for clarification arises, the ASC will contact your organization. Onsite survey The onsite survey occurs approximately eight weeks after the submission of the Survey Tool, and typically takes one day. The onsite survey consists of a brief opening/introduction, a review of the elements indicated for onsite review, completion of the review of previously submitted documentation, an interview with key personnel and a closing conference. An agenda template will be provided by NCQA. Surveyors will need a separate room to work in that is large enough to comfortably accommodate two laptops, with additional workspace for file review, if files are not electronic. Surveyors will also need Internet access through a direct high-speed line or an analog line. If you don t have either of these two types of lines available, please contact your ASC to discuss alternatives. Working lunches are part of the process. Your organization is not required to furnish meals and refreshments, but it should make them accessible to surveyors. 2007 Guidelines for Successful OC Survey 5

When to get things done We have developed a schedule to assist you in preparing for your survey. Below is a timetable of activities that must be accomplished before the onsite survey. If you have any questions, contact NCQA. Target Date The organization purchases the electronic Certification Survey Tool (ST) The organization performs a readiness evaluation of its operations and programs The organization formally notifies NCQA of readiness for accreditation and requests dates for submission of Survey Tool and onsite survey Information Due to/from NCQA No time limit is imposed on the organization s readiness evaluation preparation NCQA schedules dates for submission of the Survey Tool, the onsite survey and proposed date of 5-week conference call 6 months before scheduled submission of Survey Tool NCQA e-mails the organization with name of the assigned Accreditation Survey Coordinator (ASC) 10 weeks prior to submission NCQA e-mails the organization the names and resumes of survey team members 4 weeks prior to submission The organization submits estimates on the number of UM, ER, and appeal files, if applicable The organization emails completed draft agenda to NCQA, if applicable The organization emails the list of hotel suggestions to NCQA 3 weeks prior to submission NCQA sends the MCO a UM and appeal workbook (to select dates and number of denials and appeals) The organization submits the Survey Tool to NCQA NCQA receives the Survey Tool The organization is closed out of the Survey Tool The organization attaches file review information (credentialing, recredentialing, denials, appeals) The ASC contacts the organization with questions or concerns The ASC notifies the survey team of availability of Survey Tool 2 4 weeks after submission of the Survey Tool The ASC emails the organization contact for clarifying information on identified elements The organization submits clarifying information electronically to ASC The ASC attaches information to elements in the Survey Tool The survey team assesses clarifying information 4 weeks after submission of Survey Tool NCQA sends a delegation memo, outlining which delegates have been selected for oversight 24-48 hours prior to conference call with the organization The ASC e-mails the agenda to the organization with issues identified for the conference call 5 weeks after submission of Survey Tool The ASC moderates the scheduled conference call with the survey team and organization representatives 5-6 weeks after submission of Survey Tool The organization submits clarifying information electronically to ASC The ASC attaches information to elements in the Survey Tool 5-7 weeks after submission of Survey Tool The survey team assesses clarifying information 5 business days before on site (7 weeks after submission) NCQA e-mails the site-visit agenda to the organization 2007 Guidelines for Successful OC Survey 6

Onsite survey (8 weeks after submission) NCQA e-mails the organization file review lists for UM denials, appeals and credentialing and recredentialing file review The survey team confirms file review information during the onsite survey The NCQA onsite survey NCQA Resources Online support PCS Policy clarifications and FAQs Certification Status Lists NCQA educational seminars NCQA s Web site, www.ncqa.org, carries a wealth of information that includes recent news from NCQA, the Policy Clarification Support (PCS) system, policy clarifications and updates, a list of frequently asked questions (FAQ) and a list of NCQA conferences and publications. For questions about interpretation of the NCQA standards, contact the PCS system on the NCQA Web site at www.ncqa.org/pcs. However, once you have been assigned an ASC, you should direct all questions to your ASC. Policy clarifications and FAQs previously answered concerning MCO accreditation are available on the NCQA Web site. The NCQA Web site displays the current Certification Status Lists, indicating the status of all OCs in the NCQA Certification process. NCQA seminars provide a wealth of need-to-know information on NCQA Accreditation and Certification standards and the survey process. Seminar offerings range from an introduction to the NCQA standards to advanced techniques for quality improvement. Continuing education credits are offered for physicians and nurses. For more information about NCQA seminars, visit www.ncqa.org/education or call NCQA Customer Support at (888) 275-7585. NCQA standard and customized corporate training If your organization would benefit from sending 10 or more staff members to an NCQA seminar, consider having us bring the seminar to you instead. Our Corporate Training Programs are a great value for organizations that need to train multiple staff members or that need a program on a specialized topic. Standard corporate training brings many of our existing seminars to your site; we can even present some of our online programs. Customized corporate training enables you to work with NCQA s Education staff to design a program that meets your organization s specific needs. Both offer expert faculty, comprehensive training materials and continuing education credits for physicians and nurses. To arrange corporate training or for more information, call NCQA Customer Support at (888) 275-7585. 2007 Guidelines for Successful OC Survey 7

Recommended Supporting Documents Ensure that your documents, policies, procedures, reports and materials address all aspects of each element. The following is a list of documents recommended to present as compliance so the surveyors may complete its evaluation of your organization s compliance against the referenced standards. The list is not intended to be all-inclusive or prescriptive. Standard Documents UTILIZATION MANAGEMENT UM 1 UM program description for the past 2 years. Annual surveys and updates of the UM program for the past 2 years. UM 2 UM 3 UM 4 UM 6 UM 7 UM 8 UM 10 UM 11 UM 12 UM 13 Evidence that the organization has UM decision-making criteria that are objective and based on medical evidence. Policies for applying criteria that include their application based on individual needs and on an assessment of the local delivery system. Evidence of the involvement of practitioners in developing, adopting, and surveying criteria. The process for annual survey and update of UM criteria. Documentation to demonstrate how the organization ensures the availability of its criteria to practitioners. Documentation to demonstrate that the organization annually evaluates the consistency of how health care professionals involved in UM apply criteria in decision-making and acts on opportunities for improvement. Description of the process or policies and procedures indicating that staff are accessible to practitioners and enrollees regarding UM decisions and the UM program. Policies and procedures pertaining to licensure of health professionals involved in supervising medical necessity decisions and making UM decisions, and the use of board-certified consultants to assist in making medical necessity decisions. Job descriptions of practitioners who survey denials of care based on medical necessity. Policies and procedures regarding information needed to support UM decision-making. Policies and procedures regarding on-site survey services at facilities. Policies and procedures that describe how the organization assists enrollees when benefits end. Examples of the organization assisting enrollees with transition to other care when benefits end. Policies and procedures regarding how the organization notifies practitioners of appropriate reviewer availability. Documents used to notify practitioners about reviewer availability. Appeal policies and procedures for each product line, if different, that include preservice, postservice, expedited and external appeals. Definitions of appeal and other relevant terms (grievance, inquiry, complaint). Timeliness standards for all appeals. Clarification of whether or not each state in which the organization operates has enacted external survey legislation. Policies and procedures that describe written evaluation process of new technology and the new application of existing technologies. Examples of implementation of the policies and procedures. Description of mechanisms for monitoring enrollee and practitioner satisfaction with UM. Documents to demonstrate the annual collection of information about satisfaction with the UM process and actions taken to address identified opportunities for improvement. This standard is not included in OC certification. The number is reserved to maintain consistency with other NCQA-Accreditation programs. This standard is not included in OC certification. The number is reserved to maintain consistency with other NCQA-Accreditation programs. 2007 Guidelines for Successful OC Survey 8

Standard Documents UM 14 Clarification of whether or not the organization utilizes centralized referral and triage for behavioral health services. Clarification if this function has been delegated to an MBHO and whether or not the MBHO is NCQA- Accredited. Protocols for behavioral health care triage and referral. License requirements of practitioners who make decisions that require clinical judgment, who supervise clinical decisions and who oversee triage and referral decisions. UM 15 Written delegation agreements. Indication of any NCQA-Accredited or NCQA-Certified delegates. The process for annually approving delegates UM programs. Provisions for PHI Documentation that for delegation agreements in place less than 12 months, the organization evaluated delegate capacity before delegation began. Reports reflecting that for delegation agreements in place for longer than 12 months, the organization has annually evaluated delegates performance, has evaluated regular reports and has at least once in each of the past 2 years identified and followed up on opportunities for improvement, if applicable. CREDENTIALING CR 1 Complete CR policies and procedures, including the decision-making process, types of practitioners credentialed, verification sources used and practitioner rights. CR 2 Membership list of current Credentialing Committee. Note: Identify voting and non-voting members as well as PPO staff vs. practicing physicians that participate on your credentialing decision making body. Include the title (if applicable), and medical specialty (if applicable) for each committee member. The process for the Credentialing Committee s survey of credentials for those practitioners who do not meet criteria. Examples of instances when the Credentialing Committee has surveyed credentials of practitioners who do not meet criteria and has offered advice that the organization considers. CR 6 This standard is not included in PPO plan accreditation. The number is reserved to maintain consistency with other NCQA-Accreditation programs. CR 9 A description of the organization s methods for ongoing monitoring of sanctions, complaints and quality issues. Evidence that the organization conducts ongoing monitoring of appropriate sources and implements appropriate interventions when it identifies instances of poor quality. CR 10 Policies and procedures pertaining to taking action against a practitioner for quality reasons. Practitioner appeal policies and procedures and evidence that they have been applied appropriately. Evidence that the organization has reported practitioner suspension or termination to appropriate authorities. CR 11 Complete policies and procedures for credentialing organizational providers, including behavioral health providers. Tracking mechanisms used by the organization to assess organizational providers with which it contracts, including behavioral health providers. CR 12 Written delegation agreements. Indication of any NCQA-Accredited or NCQA-Certified delegates. Provisions for PHI. Documentation that for delegation agreements in place less than 12 months, the organization evaluated delegate capacity before delegation began. Reports reflecting that for delegation agreements in place for longer than 12 months, the organization has annually evaluated delegates performance, has annually audited files against NCQA standards, has evaluated regular reports and at least once in each of the past 2 years, has identified and followed up on opportunities for improvement, if applicable. ENROLLEES RIGHTS AND RESPONSIBILITIES 2007 Guidelines for Successful OC Survey 9

Standard RR 1 RR 2 RR 3 RR 4 RR 5 RR 6 RR 7 Documents Enrollees' RR statement (if the current statement has been in place less than 12 months, provide the previous version, as well). This standard is not included in OC certification. The number is reserved to maintain consistency with other NCQA-Accreditation programs. This standard is not included in OC certification. The number is reserved to maintain consistency with other NCQA-Accreditation programs. This standard is not included in OC certification. The number is reserved to maintain consistency with other NCQA-Accreditation programs. This standard is not included in OC certification. The number is reserved to maintain consistency with other NCQA-Accreditation programs. Complete policies and procedures for ensuring enrollee confidentiality, in particular addressing PHI. Evidence that a chief privacy officer or internal privacy committee was involved in the development and implementation of confidentiality and privacy policies and practices. Posted statements from the organization s Web site to confirm that is displays the information it collects and the use of information collected on the Web site. This standard is not included in OC certification. The number is reserved to maintain consistency with other NCQA-Accreditation programs. INTERNAL QUALITY IMPROVEMENT PROCESS QI 1 Written QI plan or written comprehensive policies and procedures. Analysis of QI indicators. QI 2 QI 3 This standard is not included in OC Certification. The number is reserved to maintain consistency with other NCQA Certification programs. Samples of active practitioner and provider contracts. This standard is not included in UM Certification. QI 4 Documentation supporting the assessment of the number and geographic distribution of practitioners and the identification of opportunities for improvement. Documentation to support interventions taken based on identified opportunities for improvement. This standard is not included in UM Certification. QI 5 Analysis of enrollee complaints related to access by using enrollee satisfaction surveys with questions related to access, and CAHPS 3.0H results. Documentation to support interventions taken based on identified opportunities for improvement. This standard is not included in UM Certification. QI 6 QI 14 These standards are not included in CR Certification. The numbers are reserved to maintain consistency with other NCQA Certification programs. PROTECTION OF CREDENTIALING INFORMATION PC 1 Policies and procedures regarding confidentiality. Policies and procedures regarding password protection. Personnel management procedures for new employees. Policies and procedures for backup and recovery. For security reasons, including the protection of the data and documents you send to us, we limit the types of documents you may send. The permitted file types are.csv,.doc,.gif,.jpg,.mpp,.pdf,.ppt,.rtf,.tif,.txt,.vsd and.xls. We cannot accept files in other formats. Please note that most other formats can be converted to.gif,.tif, or.jpg via scanner, or to.pdf using Adobe Acrobat. 2007 Guidelines for Successful OC Survey 10