Align Your Processes for LTSS Service Authorizations & Notifications with NCQA’s New Elements

By Nancy Ross Bell, RN

Estimated time to read: 3 minutes

With the 2024 Health Plan Accreditation (HPA) standards that went into effect on July 1, 2024, two new Elements for LTSS Distinction are proving to be challenging for some organizations:

• Service Authorization (LTSS 1B)
• Notification of Service Authorization (LTSS 1C)

 For both new Elements, the look-back period is prior to the survey date, applies to First and Renewal Surveys for all product lines, and requires Documented Processes.

As we review NCQA’s requirements for each factor, we also discuss recommendations from MHR’s Consultant.  

Service Authorizations (LTSS 1B 1-2)

Service authorizations include determining the amount (hours) and types of LTSS provided to members (LTSS 1B Explanation). In some organizations, LTSS requests have already been included in the health plan’s Utilization Management (UM) process. However, MHR is seeing in some cases that Documented Processes are not specific to LTSS, not specific to the level or type of request, and contain insufficient detail.

For both initial service requests and additional service requests, the Documented Process(es) must include:  

• The criteria used to authorize initial services and to add or subtract hours for additional service requests
• Documentation required of the provider by the organization
• Review of the provider’s amount (hours) and types of requested LTSS services against the organization’s criteria and member’s needs as documented in the care plan
• Timeframe for the organization to make coverage decisions
• Updating the member’s care plan with the organization's decision

MHR recommends:

• Updating existing UM policies to specifically include LTSS requirements or creating separate LTSS policies to ensure compliance
• Ensuring the member’s care plan is considered when making decisions to authorize or deny requested LTSS services
• Updating the care plan when services or hours are added or subtracted from previously approved services
• Adding when a clinical professional is required or recommended to make decisions on LTSS
• Describing how requests are decided if there are no matching criteria

Documented Processes must be specific to LTSS and in sufficient detail for each Factor to receive a score of Met (LTSS 1 B Scoring).

Notification of Service Authorizations (LTSS 1 C 1-3)

Notifications to members for LTSS decisions to deny service are similar to other UM notifications.  The organization’s Documented Process for LTSS must include:

• The specific reasons for denial in easily understandable language
• A reference to the benefit provision, guideline, protocol, or other similar criterion on which the denial decision is based.
• How the care plan is used to determine the LTSS denial decision.

All three Factors are required to Meet this Element (LTSS 1 C Scoring).

Organizations are reminded to closely review NCQA’s Explanation for the finer details of LTSS 1 C to include in the Documented Process of notifications.

• Members and professionals must understand why the organization denied the request. The Documented Process on notifications must:
  • describe the reason for the denial
  • in terms specific to the member’s condition or request
  • in language that is easy to understand, void of abbreviations, acronyms, and health care procedure codes that are not understood by a layperson
• The Documented Process must reference the criterion specific to the member’s condition or the requested services and state:
  • the name of the criterion
  • the organization or source of the criterion, including if the source is the organization itself
• The Documented Process must describe how the member’s care plan is used to guide the denial decision.

MHR recommends:

• While one Documented Process is required for LTSS 1 B, Factors 1-2, organizational processes may differ between initial requests and additional requests. Two separate Documented Processes are acceptable.
• Review denial letter templates to ensure they can accommodate language that describes how the member’s care plan is used to guide the denial decision.

Call to Action

• Contact your MHR Consultant to schedule training on the LTSS standards and to guide you in your preparation for your survey.

MHR follows a quality review process for all blogs. This blog was written with expert input from Erin Kafieh. Read more about Erin and our other consultants at ManagedHealthcareResources.com/About Our Consultants.  

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