how does ncqa accreditation help aetna

Visit the secure website, available through www.aetna.com, for more information. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. And for good reason if it were easy, just anyone could do it. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Contact us at My.NCQA to ask about licensing the ratings data for research or display. See all legal notices Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. 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). Share this page with a friend or colleague by Email. NCQA accreditation or interim accreditation, while an additional six MCPs are in the process of achieving accreditation; that is 18 of 24 currently contracted MCPs. 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. 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. 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. RESOURCES FOR HEALTH PLANS. Cost: $449 Date: Wednesday, September 14, 2022; 1-4pm ET NCQA Health Equity Accreditation Plus. Go to the American Medical Association Web site. Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. to Change Data, Security If you are considering health plan accreditation, you have likely heard of theNational Committee for Quality Assurance(NCQA). Others have four tiers, three tiers or two tiers. Login. 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. Interested in other accreditation options?Click hereto 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. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. And for good reason if it were easy, just anyone could do it. Each year, we use the results to set new goals and improve selected measures. As one of the nations leading health plans, Aetnas members represent the countrys increasing diversity in race, ethnicity and language. If you do not intend to leave our site, close this message. The standards align with many state requirements. 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. Treating providers are solely responsible for dental advice and treatment of members. Request an application. Condition-targeted health assessments for service line growth. How do I credential with UnitedHealthcare? If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. 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). 0000001025 00000 n What is a health risk assessment and how do they work? The ABA Medical Necessity Guidedoes not constitute medical advice. If you are currently accredited and want to talk to someone about your status or about renewing or adding accreditations, submit a question through My NCQA. And we improved performance on many measures. Patient-Centered Medical Home (PCMH) Health Plan Accreditation HEDIS Measures Health Innovation Summit Emphasis must be placed on encouraging healthy lifestyles, timely screenings, accessible medication and regular care. When billing, you must use the most appropriate code as of the effective date of the submission. 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. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. 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. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. startxref NCQA accreditation standards help health plans and other organizations align future initiatives with issues that are front and center for employers and states. 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. We do not share your information with third parties. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Save your favorite pages and receive notifications whenever theyre updated. Ask a Question. Providing employees of all racial and ethnic backgrounds with access to quality health care benefits and resources can help them stay healthy. If you are not currently accredited and want to learn more, contact NCQA. 0000000016 00000 n NCQA Health Plan Accreditation is a widely recognized, evidence-based program dedicated to quality improvement and measurement. What is NCQA its history and key objectives? Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Issues a contract for insurance for a defined population or contracts with an employer to provide managed care services for a self-insured population. Medi-Cal Managed Care Health Plan (MCP) Accreditation Status August 2019. More than 173 million people are enrolled in NCQA-Accredited health plans. Has a process for monitoring, evaluating and improving the quality and safety of care provided to its members, Reports audited HEDIS results for designated HEDIS. NCQA's Health Plan Ratings 2024 include commercial, Medicare and Medicaid health plans. Methodology 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). The review process is rigorous and may consist of both an onsite and offsite evaluation. 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. Applicable FARS/DFARS apply. Unlisted, unspecified and nonspecific codes should be avoided. Health Standards, Data Your benefits plan determines coverage. 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 . 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. 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. Quality Compass is a registered trademark of NCQA. 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. CPT is a registered trademark of the American Medical Association. 12 months in advance: Become familiar with NCQA's required standards and processes. Our quality improvement program helps improve the behavioral health care we provide to you. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". Reprinted with permission. (The industry standard is 10 to 20%.). The member's benefit plan determines coverage. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. Credentialing Accreditation assesses an organizations performance in the following areas: Find the Standards and Guidelines document in the NCQA Store. Contact us Get member help Aetna members have access to contact information and resources specific to their plans. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. Specifically, Aetna uses information our members voluntarily provide to: Yes. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". We updated our app and provider directory to help members easily find providers who offer telemedicine. Create and deliver quality improvement, management or assessment programs and processes. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. NCQA Accreditation as of June 30, 2022. Links to various non-Aetna sites are provided for your convenience only. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). The information you will be accessing is provided by another organization or vendor. Copyright 2015 by the American Society of Addiction Medicine. 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. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Update educational materials and articles on the provider website to ensure that information is accurate. to Fuel Marketing initiatives, Scale health risk assessment, HRA, 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. As described above, seeking accreditation is anarduous process. 0000002555 00000 n If DHCS required NCQA accreditation and followed the 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. Patient-Centered Medical Home (PCMH) Recognition Aetna is committed to Accreditation by the National Committee for Quality Assurance (NCQA) as a means of demonstrating a commitment to continuous quality improvement and meeting customer expectations. Obtain full pricing information by submitting a request through My NCQA. So why do health plans do it? Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 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. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. Certification, Readiness 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. Visit the secure website, available through www.aetna.com, for more information. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Interested in other accreditation options? Data leads to insight about member health needs, which strengthens our ability to develop targeted initiatives. New and revised codes are added to the CPBs as they are updated. Treating providers are solely responsible for medical advice and treatment of members. Credentialing services include: Verifying healthcare provider credentials through a primary source or a contracted agent of the primary source. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. When health plans work with vendors that have already passed NCQAs thorough review, they receive oversight relief for all the standards that apply.