QI
The type of Credential and Specialty for a BH Medical Director
What is MD, or clinical PhD or PsyD?
The NET standard/element with a critical factors.
NET 2 Element B. Access to BH Care
Factor 1. Non-life-threatening emergency within 6 hours.
Factor 2. Urgent care within 48 hours.
UM document that reflects objectives/goals, scope, benefit coverage, med. necessity-and BH aspect of the program
What is UM Program Description
The annual member survey.
Annual BH member experience survey focused on experience with WellSense services, and access to care/services
Next WellSense Submission
A Resurvey scheduled 10/14/2025
Standard that states practitioners/providers cooperate with QI activities and allow the use of their performance data.
QI 2 Element A-B
This CM assessment includes BH health status, substance abuse, cognitive functions
Complex Care Management Assessment
This role can deny all types of Medical Necessity decisions( Medical, behavioral healthcare, pharmaceutical, dental, chiropractic and vision denials.)
Who is a Physician
The types of BH Providers to credential.
*Behavioral healthcare practitioners:
– Psychiatrists and other physicians.
– Addiction medicine specialists.
– Doctoral or master’s-level psychologists.
– Master’s-level clinical social workers.
– Master’s-level clinical nurse specialists or psychiatric nurse practitioners.
– Other behavioral healthcare specialists who may be within the scope of credentialing (e.g., licensed professional counselor).
The PHM standard/element with a critical factor.
PHM 1 Element A -PHM Strategy , Factor 1
Components of the Trilogy Documents
QI Program Description, QI Work Plan and QI Evaluation
Network annual analysis must be conducted on these components.
•Conducts annual analysis to assess the CLAS, availability, accessibility and adequacy of care and services for each (prescribers and non-prescribers).
When this is not "Met", an organization
•must submit a CAP to NCQA within 30 calendar days of the final report. •must undergo a CAP Survey in 6 months on the affected elements to confirm implementation or completion of the CAP.
What is a Must Pass Element
MED standards are required for this State
NH-this submission is required by the State regulator not NCQA.
This assessment includes BH health status, substance abuse, cognitive functions
Complex Care Management Assessment
How we meet the new QI 2 Element C
demonstrates that we have at least one arrangement with a behavioral healthcare organization to share data for HEDIS measure performance
Consistency in application of Clinical criteria is assessed through the annual completion of
The inter-rater-reliability analysis (MDs, RNs, Pharmacist-anyone able to make a med. necessity decision. )
In order for a credentialing committee to have the appropriate structure to make decisions, it must include:
Members from the types of practitioners participating in the organization’s network. e.g., physician, oral surgeon, psychologist, psychiatrist) specialty or multidisciplinary committee, with representation from various specialties
NCQA look back period for UM and PHM files
12 months for UM and PHM files
The QI standard that uses HEDIS, CAHPS to assess coordination between medical and BH delivery system
What is QI 3 Element A-D
In 2026 standards, NCQA places emphasis on this aspect of annual UM evaluation
What are UM rates (approvals, denials and timelines of notifications)
The organization’s score cannot exceed Partially Met if one factor is scored "no" or Not Met if two or more are scored “no.”
Critical factor/s