how does ncqa accreditation help aetna

Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". Also, language and cultural barriers must be eliminated. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. Enter the email address you signed up with and we'll email you a reset link. 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. Pricing is based on multiple factors. We developed Second Curve, Here4You and other suicide prevention campaigns to move beyond awareness and drive change. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guidedoes not constitute medical advice. Data leads to insight about member health needs, which strengthens our ability to develop targeted initiatives. 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 information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Member privacy is paramount. Do you want to continue? You are now being directed to the CVS Health site. Create and deliver quality improvement, management or assessment programs and processes. Ready to learn more about the NCQA certification process? Our clinical activities and programs are based on proven guidelines. As described above, seeking accreditation is anarduous process. Who do we contact to begin credentialing with UnitedHealthcare or its affiliates? We collected data on a set of clinical measures called Healthcare Effectiveness Data and Information Set (HEDIS), as applicable. NCQA will send you the handbook and application. The member's benefit plan determines coverage. <<354B25B36AD9EC4CB456011F0DE50B5F>]>> 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. Treating providers are solely responsible for dental advice and treatment of members. We work for better health care, better choices and better health. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. 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 rigor of this process is one way that accredited organizationscan signal theircommitmentto best practices and quality measures. Download our case study to learn how vendors earn NCQA certification, and the value this recognition has brought toWellsourceclients for over a decade running. If you are not currently accredited and want to learn more, contact NCQA. We do not share your information with third parties. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. This accreditation is the latest endorsement that Aetna has received from the NCQA for its products or programs. Quickly to Meet Program needs, Certification and We have developed strict policies and procedures to protect member information including race, ethnicity and language preference information from inappropriate use and disclosure. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. 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. The health plan worked with NCQA to help test the concepts and application of the accreditation. Interested in other accreditation options? 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). We also give you and your doctors information and tools that can help you make decisions. 2 Based on results from the 2021 Aetna Disease Management Member Satisfaction Analysis. 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. For over 40 years, health plans, wellness organizations, and companies committed to improving health outcomes Some plans exclude coverage for services or supplies that Aetna considers medically necessary. NCQA Utilization Management Accreditation is a quality assessment program that focuses on consumer protection and customer service improvement. Please note also that Clinical Policy Bulletins (CPBs) 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. CPT is a registered trademark of the American Medical Association. The NCQA process was Implemented effective 3/1 8/2020 by the Credentialing Department at Aetna Better Health of Louisiana. The AMA is a third party beneficiary to this Agreement. Health plans and accreditation status: Aetna Better Health of California Scheduled If you do not intend to leave our site, close this message. 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. 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. NCQA Credentialing Accreditation is designed to ensure that organizations pursuing accreditation can maintain a high-quality network for members and contracted clients. Aetna Better Health of New Jersey. No fee schedules, basic unit, relative values or related listings are included in CPT. NCQA's Health Plan Ratings 2022. health risk assessment, The issue of health care disparities is immensely complex, but there are targeted solutions that can help us bridge the gap. (NCQA). 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. We worked with BrandWatch to get social media analysis of mental health findings for adolescents and LGBTQ/BIPOC youth. 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 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. 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. Treating providers are solely responsible for medical advice and treatment of members. These standards cover areas like care planning, measurement and quality improvement, and care monitoring, to name a few. Terms of Use, Patient-Centered Specialty Practice (PCSP), Credentials Verification Organization (CVO), Managed Behavioral Healthcare Organization (MBHO), Health Information Technology Prevalidation Programs, Virtual Seminars, Webinars and On-demand Training, Advertising and Marketing Your NCQA Status. 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. HWmoH_1A^UIi+/i6W\I_qT5=3/d6@Z*'hUMfId9oqH$v E$SG8Bo>m+w(;#ua\CVAZkY@]Ef^O?:SN9"},P:X%O{g=S<5po}#=tEWii*mF(b -.dD*Y5dmegs/kJ/1j-cv=p#eu|iBW.6Y56z NCQA Accreditation standards are intended to help organizations achieve the highest level of performance possible, and create an environment of continuous improvement. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). 3.0. We take our NCQA accreditation seriously. 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. We use information our members voluntarily provide to create our Racial and Ethnic Equity Dashboard (REED) report. Links to various non-Aetna sites are provided for your convenience only. And we improved performance on many measures. NCQA Accreditation helps health plans demonstrate their commitment to quality and accountability and provides extraordinary benefits in today's market. Help gain accreditation by the National Committee for Quality Assurance (NCQA) and other accreditation organizations. Reprinted with permission. I = Insufficient data; NC = No Credit; NA = Not Applicable . It is important to note that Aetna uses this information only to improve the quality of care for our members and not for rating, underwriting, determining insurability, marketing or premium determinations. Medi-Cal Managed Care Health Plan (MCP) Accreditation Status August 2019. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. More than 1,000 health plans have earned NCQA Accreditation and achieving accreditation is a lengthy process, representing a lot of work. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Below are some of the most frequently asked questions about NCQA Credentialing Accreditation. Accreditations See our recognition from trade associations, regulatory agencies and other governing bodies. Quality Compass is a registered trademark of NCQA. 0 0000007964 00000 n More than 90 organizations have earned NCQA Credentialing Accreditation. And for good reason if it were easy, just anyone could do it. Applicable FARS/DFARS apply. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. NCQA is ready to help! 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. When billing, you must use the most appropriate code as of the effective date of the submission. This certification signals our commitment to providing a best-in-class solution based on industry best practices and evidence-based research that will support health and improve outcomes. 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. 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. Credentialing Accreditation is for organizations that provide full scope credentialing services. Detailed Health Insurance Plan Ratings for Aetna Better Health Inc., a Pennsylvania Corporation from 2019 - 2020 . NCQA conducts the survey and determines your accreditation status within 30 days of the final review. 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. 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. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Ask a Question. If an organization allows its Accreditation status to lapse, its UM, CR or PN Accreditation status will remain in place but may not be renewed. ncqa, Assess Aetna's health care provider networks' ability to meet race, ethnicity, culture and language communication needs and preferences of our member population. 0000001465 00000 n underwritten by Aetna Life Insurance Company (Aetna). xbbbd`b``l $ u 0000014217 00000 n 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. Treating providers are solely responsible for dental advice and treatment of members. Others have four tiers, three tiers or two tiers. 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. 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). The 2024 ratings will be released electronically . 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. Some subtypes have five tiers of coverage. Please log in to your secure account to get what you need. They provide a framework for implementing evidence-based best practices. I = Insufficient data; NC = No Credit; NA = Not Applicable. endstream endobj 69 0 obj <>/Size 45/Type/XRef>>stream Organizations that earn a seal from NCQA show that they are serious about quality health care. #IP#@w"+;#j}2%0Z2 0000004063 00000 n Regulation and accreditation are not identical. NCQA Health Plan Accreditation is a widely recognized, evidence-based program dedicated to quality improvement and measurement. 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. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. Health Standards, Data Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation. For language services, please call the number on your member ID card and request an operator. Health Care Accreditation, Health Plan Accreditation Organization - NCQA - NCQA The National Committee for Quality Assurance (NCQA) exists to improve the quality of health care. 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. Providers can receive the most effective, stress-free service. CPT is a registered trademark of the American Medical Association. NCQA Accreditation as of June 30, 2019. Copyright 2023 National Committee for Quality Assurance. 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. Members should discuss any matters related to their coverage or condition with their treating provider. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. We launched an evidence-based 12-week pilot program with OUI Therapeutics/Vita Health for adults 18+ delivered virtually by clinical specialists to help lower suicide risk. To improve satisfaction, we: Improved the accuracy of our provider directory information, Improved online self-service options for members and providers, We surveyed members in the Aetna Case Management program. 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). Others have four tiers, three tiers or two tiers. HRA, 0000017970 00000 n 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. We created social media campaigns forLGBTQ and BIPOC youth. NCQA's Health Plan Ratings 2024 include commercial, Medicare and Medicaid health plans. 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. The typical evaluation time frame is 12 months from application submission to decision, depending on an organizations readiness. and Compliance, Evidence-Based At least 9 months in advance: Conduct an analysis comparing current processes to NCQA requirements and adjust as necessary. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. 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. Performs functions addressed in the standards, either directly or through a service agreement. 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. 0000001192 00000 n The overall rating is the weighted average of a plan's HEDIS and CAHPS measure ratings, plus bonus points for plans with a current Accreditation status as of June 30, 2024. Aetna Student Health is the brand name for products and services provided by Aetna Life Insurance Company and its applicable affiliated companies (Aetna). \t_=)@S. 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. The NCQA bases its general accreditation fee on a formula of $39,750 plus 16 cents per member if the plan's membership is over 50,000. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. The NCQA makes the results public. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. Credentialing and recredentialing processes. NCQA health plan accreditation is a widely-recognized, evidence-based program that works to ensure quality improvement and measurement through aligning organizations with a comprehensive framework. 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's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). You will be prompted to log in to your NCQA account. Methodology 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. Explore health plan accreditation with Wellsource. Notification to Authorities and Practitioner Appeal Rights. Recognition, Download Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. Or ask a question through My NCQA. to Fuel Marketing initiatives, Scale This information is neither an offer of coverage nor medical advice. Engage members through pre-clinical coaching to address mental health issues before they become a crisis. The ABA Medical Necessity Guidedoes not constitute medical advice. The overall rating is the weighted average of a plan's HEDIS and CAHPS measure ratings, plus bonus points for plans with a current Accreditation Please be sure to add a 1 before your mobile number, ex: 19876543210. READ SOMETHING ELSE 0000002520 00000 n %%EOF Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. We updated our app and provider directory to help members easily find providers who offer telemedicine. In case of a conflict between your plan documents and this information, the plan documents will govern.