45 0 obj <> endobj Below are some of the most frequently asked questions about NCQA Health Plan Accreditation. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. Legal notices We also give you and your doctors information and tools that can help you make decisions. No fee schedules, basic unit, relative values or related listings are included in CPT. License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). Program Evaluation Treatment Outcome Questionnaires Models, Organizational Health Care Surveys Pilot Projects Data Collection Prospective Studies Reproducibility of Results Electronic Health Records Retrospective Studies Cross-Sectional Studies Research Design Follow-Up Studies Ambulatory Care Interviews as Topic Feasibility . See Accreditation status and health plan rating for Aetna Health Inc. (New Jersey) on NCQA Report Cards. Improved our patient safety programto help members make informed health choices, Used social media to share patient safety information, Provided patient safety resources to physicians on the secure provider website. NCQA Accreditation Earning NCQA's Accreditation of Case Management for LTSS demonstrates that an organization is dedicated to coordinating the delivery of care in a person-centered and integrated manner to help individuals function optimally in their preferred setting. Please log in to your secure account to get what you need. The Ultimate Guide to Health Risk Assessments, A Large Employer Realizes Over $85,000 in Direct ROI from the Wellsource HRA, Checklist: Choosing the Right Health Risk Assessment, If you are considering health plan accreditation, you have likely heard of the. This workgroup will provide input on topics related to the standards and processes of requiring all MCPs to obtain NCQA accreditation, including consideration of the proposed accreditation requirements. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Do you want to continue? Contact us at My.NCQA to ask about licensing the ratings data for research or display. Pay the Final Fee and Earn Your License. For over 40 years, health plans, wellness organizations, and companies committed to improving health outcomes License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Please note that NCQA does not endorse MCG Health's solutions, or require the use of MCG care guidelines to achieve accreditation. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Workgroup Charter Call a licensed agent at 1-855-335-1407 (TTY: 711) , 7 days a week, 8 AM to 8 PM. 12 months in advance: Become familiar with NCQA's required standards and processes. The member's benefit plan determines coverage. UPMC for You is one of five medicaid plans in Pennsylvania to earn an overall rating of 4 out of 5 in NCQA's Medicaid Health Insurance Plan Health Insurance Plan Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses As with other types of insurance is risk . At the very least, patients must be given tools that help them to speak more confidently and effectively with their health care providers so that they can take greater control of their health and well-being. %PDF-1.4 % Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. As a result, many MCPs already follow NCQA guidelines with regard to care coordination or population health management. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. In case of a conflict between your plan documents and this information, the plan documents will govern. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. Agreement and Collaboration With Clients. Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). Go to the American Medical Association Web site. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. Certification, Readiness Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. The Benefit ofWorking with Certified Vendors to Achieve Health Plan Accreditation, As described above, seeking accreditation is anarduous process. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. The typical evaluation time frame is 12 months from application submission to decision, depending on an organizations readiness. Please be sure to add a 1 before your mobile number, ex: 19876543210, follow-up care for children prescribed ADHD medication (ADD), screen for co-existing mental health and substance use disorders, Measure, monitor and improve clinical care and quality of service, Launch company-wide initiatives to improve the safety of our members and communities, Make sure we obey all the rules, whether they come from plan sponsors, federal and state regulators, or accrediting groups, Developing policies and procedures that meet clinical practice standards, Reviewing preventive and behavioral health services and how care is coordinated, Addressing racial and ethnic disparitiesin health care that could negatively impact quality health care, Monitoring the effectiveness of our programs, Studying the accessibility and availability of ournetwork providers, Monitoring the overuse and underuse of services for our Medicare members, Performing credentialing and recredentialing activities, Assessing member and provider satisfaction. NCQA Health Insurance Plan Ratings 2019-2020 - Detail Report (Private) Plan Name: Aetna Life Insurance Company (Ohio) Rating: 3.5. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Quickly to Meet Program needs, Certification and Credentialing and recredentialing processes. Measure the performance and outcomes of our programs and processes. Help gain accreditation by the National Committee for Quality Assurance (NCQA) and other accreditation organizations. Satisfaction remained high, and members are likely to recommend the program. 1 Based on results from the 2021 Aetna Case Management Member Satisfaction Analysis. Our quality improvement program helps improve the behavioral health care we provide to you. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Maintain Your License. Members should discuss any matters related to their coverage or condition with their treating provider. Update educational materials and articles on the provider website to ensure that information is accurate. 3 months before the survey start date: an Accreditation Services Coordinator from NCQA will contact your organization. Any organization that provides managed health care services can apply for the NCQA Health Plan Accreditation if it meets the following criteria: The first step to earning accreditation is a discussion with an NCQA program expert. The National Committee for Quality Assurance's (NCQA) Diabetes Recognition Program (DRP) recognizes clinicians who have met standards demonstrating delivery of high-quality care to patients with diabetes. An organization that earns Accreditation meets standards covering more than 100 measured elements. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Over 1,000 health plan products have earned NCQA Health Plan Accreditation. Our provider network increased 6% in 2021. Please be sure to add a 1 before your mobile number, ex: 19876543210. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. NCQA Utilization Management Accreditation is a quality assessment program that focuses on consumer protection and customer service improvement. This accreditation is the latest endorsement that Aetna has received from the NCQA for its products or programs. Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. What makes for an engaging health and wellness program? health plans. More than 1,000 health plans have earned NCQA Accreditation and achieving accreditation is a lengthy process, representing a lot of work. Who do we contact to begin credentialing with UnitedHealthcare or its affiliates? Treating providers are solely responsible for dental advice and treatment of members. All services deemed "never effective" are excluded from coverage. to Change Data, Security By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. Request an application. Regulation and accreditation are not identical. Explore health plan accreditation with Wellsource. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. And we improved performance on many measures. Kristine works at Ncqa as Assistant Vice President of State Affairs. Health Standards, Data 0000001935 00000 n Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. to learn more about how Wellsource products help organizations prove to accrediting bodies that their programs can measure health risks, segment and stratify populations, target interventions, and provide health education and self-management tools. We use information our members voluntarily provide to create our Racial and Ethnic Equity Dashboard (REED) report. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. CPT is a registered trademark of the American Medical Association. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. Reprinted with permission. Understand your population's health risks and improve health outcomes. NCQA Accreditation as of June 30, 2022. And for good reason if it were easy, just anyone could do it. Our clinical activities and programs are based on proven guidelines. Health Plan Accreditation Our industry-leading accreditation is a rigorous assessment of health plans' structure and process, clinical quality and patient satisfaction . Visit the secure website, available through www.aetna.com, for more information. I = Insufficient data; NC = No Credit; NA = Not Applicable. Additionally, racial and ethnic information is important to a persons health plan. Issues a contract for insurance for a defined population or contracts with an employer to provide managed care services for a self-insured population. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. Obtain full pricing information by submitting a request through My NCQA. 0000018200 00000 n (NCQA). Links to various non-Aetna sites are provided for your convenience only. 2 Based on results from the 2021 Aetna Disease Management Member Satisfaction Analysis. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. NCQA Credentialing Accreditation is a comprehensive program that evaluates the operations of organizations providing full-scope credentialing services, which include verifying practitioner credentials, designated credentialing-committee review of practitioners and monitoring practitioner sanctions. Credentialing Accreditation is for organizations that provide full scope credentialing services. Login. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. %%EOF The health plan worked with NCQA to help test the concepts and application of the accreditation. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Establish a baseline representative of the demographic composition of Aetnas membership; and. Some subtypes have five tiers of coverage. As one of the nations leading health plans, Aetnas members represent the countrys increasing diversity in race, ethnicity and language. This search will use the five-tier subtype. trailer /Size 49 /Info 8 0 R /Root 10 0 R /Prev 21523 /ID[060e888545013965100abd54e3afe5c1>060e888545013965100abd54e3afe5c1>] >> startxref 0 %%EOF 10 0 obj /Type . We have developed strict policies and procedures to protect member information including race, ethnicity and language preference information from inappropriate use and disclosure. Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. You are now being directed to CVS Caremark site. 0000004063 00000 n The NCQA process was Implemented effective 3/1 8/2020 by the Credentialing Department at Aetna Better Health of Louisiana. 0000001781 00000 n HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Credentialing Accreditation assesses an organizations performance in the following areas: Find the Standards and Guidelines document in the NCQA Store. NCQA Confers Health Equity Accreditation on Elevance Health Medicaid Plans Aetna Medicaid Plan Recognized by NCQA for Health Equity Efforts UnitedHealthcare Grants Address Social Determinants of . The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. The accreditations come after Aetna Better Health of Michigan, Inc., participated in an eight-month NCQA sponsored pilot to develop its Health Equity Accreditation Plus evaluation program. The information you will be accessing is provided by another organization or vendor. 0 The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). HRA, Applicable FARS/DFARS apply. 0000002555 00000 n NCQA conducts the survey and determines your accreditation status within 30 days of the final review. Regulation involves rules that must be followed, while accreditation is a seal of approval (from some independent accrediting body) certifying that an organization or individual has met specific standards. NCQA's Health Plan Ratings 2022. Health Care Accreditation, Health Plan Accreditation Organization - NCQA - NCQA The National Committee for Quality Assurance (NCQA) exists to improve the quality of health care. Health benefits and health insurance plans contain exclusions and limitations. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Data leads to insight about member health needs, which strengthens our ability to develop targeted initiatives. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Were working hard to improve the service, quality and safety of health care. NCQA is ready to help! We do not share your information with third parties. Members also told us the information they learned from the program had a positive effect on their lives, and their health improved because of the program. Applicable FARS/DFARS apply. Find opportunities to ensure equitable access to health care. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. Learn about our efforts and how far weve come. In 2019, NCQA rated more than 1,000 health insurance plans based on clinical quality, member satisfaction and NCQA Accreditation Survey results. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. URL: www.aetna.com. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.
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