In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. 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. 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. NCQA's Health Equity Accreditation Plus helps health care organizations that have implemented core Health Equity Accreditation activities establish processes and cross-sector partnerships that identify and address social risk factors in their communities and the social needs of the people they serve. Some organizations may already be working within NCQA guidelines. Racial and ethnic equity FAQs | Aetna The NCQA makes the results public. 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. 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. Quickly to Meet Program needs, Certification and Regulation and accreditation are not identical. NCQA's Health Plan Ratings 2024 include commercial, Medicare and Medicaid health plans. 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. Submit an inquiry through My NCQA. learn more URAC Accreditation for Health Call Center May 1, 2021 - May 1, 2024 Optum Serve Learn more 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. Quality Compass is a registered trademark of NCQA. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. 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. 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. Reprinted with permission. Treating providers are solely responsible for medical advice and treatment of members. 1 Based on results from the 2021 Aetna Case Management Member Satisfaction Analysis. 0000007741 00000 n It's how we show our commitment to improving your quality of care, access to care and member satisfaction. Update educational materials and articles on the provider website to ensure that information is accurate. 0000000016 00000 n Explore health plan accreditation with Wellsource. 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. Currently, 14 MCPs are accredited and 15 MCPs are not accredited. 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. Reprinted with permission. CPT only copyright 2015 American Medical Association. NCQA Credentialing Accreditation Received | 5ACVO 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. This accreditation is the latest endorsement that Aetna has received from the NCQA for its products or programs. 0000004063 00000 n Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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. Here's what we did in 2021: Enhancing health and mental well-being leads to a better quality of life. Credentialing and recredentialing processes. 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. The standards focus on: Quality Management and Improvement Population Health Management Network Management The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 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. We launched our Caring Contacts program to provide resources and support to Aetna members discharged from an inpatient setting after a suicide attempt. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. NCQA Reviews the Application. 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. 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. 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. FAQs - Credentialing - NCQA The standards align with many state requirements. kBtUp+v;J~)k>x@4l1%RuMALe0>6L(h(yI nL`suT;,y=PO#f{{0!4H6ISwB1"`rX`\'J$tS Copyright 2023 National Committee for Quality Assurance. 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. 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. 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 first step to earning accreditation is a discussion with an NCQA program expert. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. 0000004213 00000 n NCQA conducts the survey and determines your accreditation status within 30 days of the final review. xbbbd`b``l $ u (PDF) A Profile of Medicaid Managed Care Programs in 2010: Findings Analytical, Diagnostic and Therapeutic Techniques and Equipment 41. Ratings emphasize care outcomes (the results of care) and what patients say about their care. Why Is NCQA Accreditation Important? - Wellsource In case of a conflict between your plan documents and this information, the plan documents will govern. Links to various non-Aetna sites are provided for your convenience only. (NCQA). 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. 12 months in advance: Become familiar with NCQA's required standards and processes. Operates under an insurance license (e.g., HMO, POS, PPO, EPO). 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. See the NCQA Report Card for a directory of accredited organizations. Aetna Health Inc. . If you do not intend to leave our site, close this message. You are now being directed to the CVS Health site. 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. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. trailer Some subtypes have five tiers of coverage. Efforts to reduce disparities in health care could ultimately improve care and reduce overall health care costs. 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). Ask a Question. Data leads to insight about member health needs, which strengthens our ability to develop targeted initiatives. 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. We are committed to improving services for preventive health, early detection and disease management for health conditions commonly seen in specific racial or ethnic groups. NCQA accreditation standards help health plans and other organizations align future initiatives with issues that are front and center for employers and states. 0 0000004508 00000 n Pricing is based on multiple factors. CPT is a registered trademark of the American Medical Association. NCQA Accreditation as of June 30, 2022. We collected data on a set of clinical measures called Healthcare Effectiveness Data and Information Set (HEDIS), as applicable. When health plans work with vendors that have already passed NCQAs thorough review, they receive oversight relief for all the standards that apply. Links to various non-Aetna sites are provided for your convenience only. 45 0 obj <> endobj While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Maintain Your License. The information contained in this article concerns the MCG care guidelines in the specified edition and as of the date of publication and may not reflect revisions made to the guidelines or any other developments in the subject matter after the publication date . 70 0 obj <>stream Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". Each main plan type has more than one subtype. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. NCQA Certification products represent a subset of the standards and guidelines for our Accreditation products and are appropriate for organizations that provide specific services, but not comprehensive programs. We piloted new programs to help members manage addiction, depression, anxiety and eating disorders. More than 90 organizations have earned NCQA Credentialing Accreditation. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. PDF National Medicaid - Quality Management Accreditation COMMUNICATION - Aetna 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). We work for better health care, better choices and better health. 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). 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). Our provider network increased 6% in 2021. 0000001465 00000 n 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. An organization that earns Accreditation meets standards covering more than 100 measured elements. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. to Fuel Marketing initiatives, Scale Engage members through pre-clinical coaching to address mental health issues before they become a crisis. Wellsourceis a certified vendor with NCQA. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. FAQs - Health Plan Accreditation - NCQA How do I credential with UnitedHealthcare? Some subtypes have five tiers of coverage. We expanded support to youth ages 12 to 25 through OUI Therapeutics/Vita Health. Do you want to continue? We have developed strict policies and procedures to protect member information including race, ethnicity and language preference information from inappropriate use and disclosure. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Together with Autism Comprehensive Educational Services (ACES), weve created the first Aetna Institute of Quality (IOQ) for autism. Emphasis must be placed on encouraging healthy lifestyles, timely screenings, accessible medication and regular care. Align your organizations processes with the standards. 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). 0000002094 00000 n Review Handbook and Application. Health Insurance Providers Texas Patient-Centered Medical Home (PCMH) Health Plan Accreditation HEDIS Measures Health Innovation Summit The 2024 ratings will be released electronically . 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. Please log in to your secure account to get what you need. Treating providers are solely responsible for medical advice and treatment of members. NCQA Health Insurance Plan Ratings Detail (The industry standard is 10 to 20%.). Or ask a question through My NCQA. 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. NCQA's Health Plan Ratings 2024 - NCQA 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. READ SOMETHING ELSE NCQA > Accreditation - National Committee for Quality Assurance In 2005 and 2006, the NCQA recognized Aetna for reducing cultural gaps in health care access, and in 2006, Aetna was also the only insurer to receive the prestigious "Recognizing Innovation in Multicultural Health Care Award" from . 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 AMA is a third party beneficiary to this Agreement. Thankfully, NCQA has streamlined part of the process through its vendor certification program, in which vendors can be vetted for quality by NCQAsee the full directory of approved vendors and accredited organizations here. Were working hard to improve the service, quality and safety of health care. See Accreditation status and health plan rating for Aetna Health Inc. (New Jersey) on NCQA Report Cards. 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. NCQA will send you the handbook and application. 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. Below are some of the most frequently asked questions about NCQA Health Plan Accreditation. ncqa, 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. Submit the Application and Pay the Application Fee. No fee schedules, basic unit, relative values or related listings are included in CPT.

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