QI Corner

[In each InteCare Provider Newsletter the Quality Improvement staff will be sharing some key information for the providers within our Network as well as our Customers about our organization.]

If you provide services to individuals involved in Managed Medicaid programs within the State of Indiana, you should know that the State is requiring both Managed Care and Managed Behavioral Healthcare contractors to be accredited by the National Committee for Quality Assurance (known as NCQA). The reason this is important to know is if you are providing services to members who are affiliated with the Hoosier Healthwise, Care Select or Healthy Indiana programs there are certain NCQA standards that providers are expected to meet. A few of these standards are as follows:

  • For members being dis- charged from an inpatient psychiatric hospitaliza- tion, they must be seen for an outpatient follow up appointment within seven (7) calendar days from the date of the member’s dis- charge
  • Members must be able to access care within 6 hours for a non-life-threatening emergency
  • Members must be able to access care within 48 hours for urgent situations
    (NCQA defines Urgent care as “A request for medical care or treatment with respect to which the application of the time periods for making nonurgent care determinations: could seriously jeopardize the life or health of a member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment, or In the opinion of a practitioner with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.”)
  • Members must have access for a routine appointment within 10 business days

NCQA requires the Managed Care and Managed Behavioral Healthcare organizations to assess and monitor how well their Provider Network is meeting these standards in order to ensure that members are receiving timely and appropriate care and services. Some organizations are initiating a “secret shopper” process in order to collect this information. In this situation, a staff member may call using a particular vignette that would mirror an urgent need or a routine request for services. Once through the call, the staff person would receive an offered date and time for their appointment which would obviously tell them if the appointment was offered within the designated standard. This is just one way that some of this information can be assessed and monitored.

In order to assess that members are receiving follow up care within seven (7) calendar days following a psychiatric hospitalization, Managed Care and Managed Behavioral Healthcare organizations use claims data. This will tell them the date of discharge from the inpatient facility along with the first allowed claims code for an outpatient visit (e.g. CPT Code 90801).

If you have any questions about NCQA or these standards, please contact Becca Sigafus at (317) 237 -5773 or email at Bsigafus@intecare.org or Jill Derryberry at (317)829-5747 or email at Jderryberry@intecare.org.