HEALTH PLANS BENEFIT FROM USING NCQA PHM PREVALIDATED VENDOR SOLUTIONS

By Nancy Ross Bell

Word count:  617

Estimated time to read:   4 minutes

Anyone involved with NCQA’s groundbreaking 2018 standards on Population Health Management (PHM) knows what an extraordinary task it was to compile and stratify data from multiple systems across the enterprise!  Vendors responded by building sophisticated HIT solutions while NCQA rolled out a new process to help organizations. What resulted was NCQA’s Population Health Management (PHM) Prevalidation process. This blog focuses on the benefits to organizations that use vendors that are NCQA PHM Prevalidated.

What is Prevalidation?

Vendors that provide HIT solutions for one or more PHM functions, including risk stratification, data aggregation, case management, and population assessment, can apply to NCQA for approval that its technology supports specific NCQA standards and helps organizations save time while producing valuable reports. This Prevalidation process indicates that the vendor’s HIT solutions were found to meet certain elements for one or more of the PHM functions for specific Accreditation programs.

How do organizations benefit from NCQA PHM Prevalidation?  

NCQA PHM Prevalidation supports four Accreditation programs:

• Case Management
• Health Plan
• Managed Behavioral Healthcare Organization
• Population Health Program

Organizations benefit the most from using vendors whose HIT solutions were approved by NCQA as Eligible for Automatic Credit, meaning organizations may receive a score of met for the following 2023 standards and elements:

• HP PHM 2A, 2B, 2D, 5B
• MBHO QI 8A, 8D, 8F
• PHP 2A, 3A, 4A
• CM 2A (factor 1), 4A

HIT solutions not approved by NCQA as Eligible for Automatic Credit may be designated as Organization Support if their HIT solution meets NCQA requirements but they do not perform the functions directly. However, the vendor’s software can provide the data fields from which organizations may pull data for their required reports.

What are the organization’s responsibilities?

• Determine whether the vendor has been approved for Eligible for Automatic Credit or Organization Support.

Currently, there are 18 vendors representing multiple HIT products on NCQA’s list for PHM Prevalidation.

• Request a copy of the vendor’s NCQA PHM Prevalidation Letter of Eligibility and identify the standards, elements, and factors to which NCQA has provided Do not assume that a vendor’s tool supports all requirements.
• Stay current on version upgrades in use and review the vendor’s Letter of Eligibility against the version being used. Material differences may require a reassessment by NCQA.
• Assess the percent of your population(s) for which the tool applies. Automatic credit can only be applied if the organization uses the vendor’s solution for 70% or more of the applicable population.
• Submit the vendor’s Letter(s) of Eligibility and your agreement with the vendor for your NCQA survey.

What is the process for vendors to become NCQA PHM Prevalidated?

Vendors undergo a rigorous process to demonstrate their tools, capabilities, and ability to meet NCQA requirements. Their process is very different from the typical submission in that they have evaluations by NCQA staff in real time.

For vendors who modify their systems or enhance capabilities, such as adding Case Management, MHR consultants assess their system against the NCQA PHM Prevalidation standards and their alignment with PHM functions.

Some vendors wish to add value by increasing compliance with health plan utilization management denials and appeals for NCQA and CMS requirements. The MHR consultants also assist with these areas.

Read more about the vendor’s process in our blog, Vendors Benefit from PHM Prevalidation of Health IT Tools.

Call to Action:    

• Contact MHR for evaluation when seeking initial accreditation to assure your plan’s systems align with NCQA standards.
• Contact MHR when adding accreditation areas or expanding value with other software areas, such as NCQA’s utilization management denials and appeals or CMS requirements.