how does ncqa accreditation help aetna how does ncqa accreditation help aetna

The ABA Medical Necessity Guidedoes not constitute medical advice. If you dont see what youre looking for below, you can search NCQAs database of additional common questions for Medicare, Medicaid and commercial plans. Health benefits and health insurance plans contain exclusions and limitations. Assess Aetna's health care provider networks' ability to meet race, ethnicity, culture and language communication needs and preferences of our member population. Asthma drug management Did people, . 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. The standards focus on: Quality Management and Improvement Population Health Management Network Management Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organizations survey readinessthe tool calculates your potential survey score. 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 . Methodology Workgroup Charter Methodology We shared the results with the National Committee for Quality Assurance (NCQA) Quality Compass. When billing, you must use the most appropriate code as of the effective date of the submission. We piloted new programs to help members manage addiction, depression, anxiety and eating disorders. Copyright 2023 National Committee for Quality Assurance. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The Benefit ofWorking with Certified Vendors to Achieve Health Plan Accreditation, As described above, seeking accreditation is anarduous process. The issue of health care disparities is immensely complex, but there are targeted solutions that can help us bridge the gap. We also work closely with numerous national health care organizations that have identified racial and ethnic disparities in health care as an issue that needs attention and action. 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. Your benefits plan determines coverage. Contact us at My.NCQA to ask about licensing the ratings data for research or display. When expanded it provides a list of search options that will switch the search inputs to match the current selection. 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). More than 1,000 health plans have earned NCQA Accreditation and achieving accreditation is a lengthy process, representing a lot of work. 0 Ratings emphasize care outcomes (the results of care) and what patients say about their care. Eligible organizations: Note: A practitioner network is the practitioner network of clients and organizations. More than 173 million people are enrolled in NCQA-Accredited health plans. 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. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. The first step to earning accreditation is a discussion with an NCQA program expert. Efforts to reduce disparities in health care could ultimately improve care and reduce overall health care costs. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). NCQA requirements are a roadmap for improvementorganizations use them to perform a gap analysis and align improvement activities with areas that are most important to states and employers, such as network adequacy and consumer protection. Help gain accreditation by the National Committee for Quality Assurance (NCQA) and other accreditation organizations. Copyright 2023 National Committee for Quality Assurance. Visit the secure website, available through www.aetna.com, for more information. In addition to creating our own initiatives to fight disparities among our members, we encourage researchers at the nations top academic institutions and engage community-based organizations to address variations in health status and health care delivery among racial and ethnic populations. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Open Choice PPO, Aetna Select, Elect Choice EPO, OA Elect Choice EPO, Open Access Aetna Select NCQA Accreditation as of June 30, 2022 I = Insufficient data; NC = No Credit; NA = Not Applicable Contact us at My.NCQA to ask about licensing the ratings data for research or display. No fee schedules, basic unit, relative values or related listings are included in CPT. New and revised codes are added to the CPBs as they are updated. Save your favorite pages and receive notifications whenever theyre updated. 0000014217 00000 n U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. Lets take a look at the benefits of going with a certified vendor in the example use case of using health risk assessments (HRAs). Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. For language services, please call the number on your member ID card and request an operator. Standards recognize that organizations that apply for accreditation have open access networks, and can improve service quality and utilize customized structures to meet purchaser needs. Links to various non-Aetna sites are provided for your convenience only. Do you want to continue? You will be prompted to log in to your NCQA account. Aetna has taken a leadership role in finding and implementing solutions to the problem of health care disparities and for 10 years has been a catalyst for change. and achieving accreditation is a lengthy process, representing a lot of work. Purchase and review the program resources, conduct a gap analysis and submit your online application. They provide a framework for implementing evidence-based best practices. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. For a healthcare organization to earn an NCQA Health Plan Accreditation, it is required to meet standards encompassing more than 100 measured elements. Currently, 14 MCPs are accredited and 15 MCPs are not accredited. Wellsourceis a certified vendor with NCQA. trailer Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. Some organizations may already be working within NCQA guidelines. Ask a Question. NCQA Credentialing Accreditation is designed to ensure that organizations pursuing accreditation can maintain a high-quality network for members and contracted clients. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. 70 0 obj <>stream Medi-Cal Managed Care Health Plan (MCP) Accreditation Status August 2019. Please log in to your secure account to get what you need. If you are not currently accredited and want to learn more, contact NCQA. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. health risk assessment, This accreditation is the latest endorsement that Aetna has received from the NCQA for its products or programs. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. More people are using telemedicine. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. Interested in other accreditation options? The information you will be accessing is provided by another organization or vendor. Align your organizations processes with the CR standards. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. The typical evaluation time frame is 12 months from application submission to decision, depending on an organizations readiness. 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). Thankfully, NCQA has streamlined part of the process through its vendor certification program, in which vendors can be vetted for quality by NCQA, see the full directory of approved vendors and accredited organizations here. Success of our initiatives will be achieved if we can: In the end, true success will come when our members achieve improved health outcomes as a result of our targeted initiatives and programs. 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. Use the report cards to find health plans, practices, clinicians or other partners that meet NCQA standards and can help you drive improvement, keep people healthy and reduce health care costs. Simply call UnitedHealthcare at 877-842-3210, say or enter your tax identification number (TIN), and then say, as prompted, Other Professional Services > Credentialing > Medical > Join the Network.. How long does it take to be credentialed with UnitedHealthcare? Detailed Health Insurance Plan Ratings for Aetna Better Health Inc., a Pennsylvania Corporation from 2019 - 2020 . 3.0. 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. NCQA surveys require six months of data, so by the time you're six months away from your survey's start date, you should be fully compliant with NCQA standards. 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. What makes for an engaging health and wellness program? 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. We use information our members voluntarily provide to create our Racial and Ethnic Equity Dashboard (REED) report. We work for better health care, better choices and better health. You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Health plan accreditation requires the use of HRAs and self-management toolsand though organizations seeking accreditation can opt to build their own HRA or partner with a third-party for the solution, many find themselves weighing the pros and cons of building their own solution and opting instead to partner with a trustworthy vendor. The member's benefit plan determines coverage. Need help with Medicare enrollment? 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. Submit the Application and Pay the Application Fee. 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. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. All Rights Reserved. It provides a comprehensive framework for organizations to align and improve operations in areas that are most important to states, employers and consumers. I = Insufficient data; NC = No Credit; NA = Not Applicable . Ratings emphasize care outcomes (the results of care) and what patients say about their care. Kristine works at Ncqa as Assistant Vice President of State Affairs. READ SOMETHING ELSE For language services, please call the number on your member ID card and request an operator. CPT only copyright 2015 American Medical Association. 0000007276 00000 n If you dont see what youre looking for below, you can search NCQAs database of additional common questionsor ask a question through My NCQA. Collect, maintain and present data on race and ethnicity that leads to the development of effective member education, health prevention and patient care management programs. REPORT CARDS. Call a licensed agent at 1-855-335-1407 (TTY: 711) , 7 days a week, 8 AM to 8 PM. Do you want to continue? xbbbd`b``l $ u Update educational materials and articles on the provider website to ensure that information is accurate. The standards provide a framework for adopting industry best practices to accurately and efficiently credential and recredential health care professionalsensuring that medical organizations employ qualified professionals and align with state requirements. 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. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. The NCQA process was Implemented effective 3/1 8/2020 by the Credentialing Department at Aetna Better Health of Louisiana. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. Go to the American Medical Association Web site. Members should discuss any matters related to their coverage or condition with their treating provider. ,) V-Wz/"HESru66x k#1:1eM8Q g`$d(d|jJ\]7CY]h:tUf5u{;=== fJ*F=(W3OiLz}mLT EN"TPrr5[U1 UEpQ_(!`9%1pcrYfgNrLB,e~'usgg=E@gIU wFGfMK_* T@F2w\0t~Xx[J4pKqa}o* ]xqx03P^=NcjdU1al7%D2y'AL,,UB,b6 Others have four tiers, three tiers or two tiers. What is a health risk assessment and how do they work? 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). I am a results-driven Health Services professional with over 15 years of experience in Collecting, Organizing, Interpreting, Disseminating various types of data, Project/Program Management . For example, we work with groups of doctors and other health professionals to make health care better. Go to the American Medical Association Web site. Companies use NCQA-certified HRAs and self-management tools because they know they provide quality data and a quality experience for the individuals who take them. 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. Treating providers are solely responsible for medical advice and treatment of members. 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. You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. 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. Each main plan type has more than one subtype. As described above, seeking accreditation is anarduous process. 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. Provides services through an organized delivery system that includes ambulatory and inpatient health care sites. Build vs. Buy: Which Health Risk Assessment Approach is Right for You. Regulation and accreditation are not identical. 0000017970 00000 n 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. 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. \t_=)@S. 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. 0000013951 00000 n 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. The information you will be accessing is provided by another organization or vendor. Learn about our efforts and how far weve come. Links to various non-Aetna sites are provided for your convenience only. Additionally, racial and ethnic information is important to a persons health plan. All Rights Reserved. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Specifically, Aetna uses information our members voluntarily provide to: Yes. If you do not intend to leave our site, close this message. What is NCQA its history and key objectives? No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Were working hard to improve the service, quality and safety of health care. Share this page with a friend or colleague by Email. Unlisted, unspecified and nonspecific codes should be avoided. Cost: $449 Date: Wednesday, September 14, 2022; 1-4pm ET NCQA Health Equity Accreditation Plus. RESOURCES FOR HEALTH PLANS. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. The AMA is a third party beneficiary to this Agreement. Accreditation HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). hbspt.cta._relativeUrls=true;hbspt.cta.load(3949674, '00e7b261-db89-4360-9393-9d0dda543729', {"useNewLoader":"true","region":"na1"}); Tags: health plans. Please expect to purchase texas premier hmo and health insurance providers texas health. At least 9 months in advance: Conduct an analysis comparing current processes to NCQA requirements and adjust as necessary. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". trailer /Size 49 /Info 8 0 R /Root 10 0 R /Prev 21523 /ID[060e888545013965100abd54e3afe5c1>060e888545013965100abd54e3afe5c1>] >> startxref 0 %%EOF 10 0 obj /Type . 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. We expanded support to youth ages 12 to 25 through OUI Therapeutics/Vita Health. ages 5 to 64, with persistent asthma have an appropriate ratio of asthma medications to help control their symptoms? NCQA accreditation standards help health plans and other organizations align future initiatives with issues that are front and center for employers and states. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 2 Based on results from the 2021 Aetna Disease Management Member Satisfaction Analysis. The most important step employers can take is to encourage their employees to voluntarily provide information on their race and ethnicity to both their doctor and their health plan. Below are some of the most frequently asked questions about NCQA Credentialing Accreditation. We take our NCQA accreditation seriously. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. 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 were the first health appraisal vendor to be certified by NCQA and have received certification continuously since 2008. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. NCQA Credentialing Accreditation assesses any organization that offers credentialing services to ensure the organization can maintain a superior network for its contracted clients.