Question

There are five NCQA standards and guidelines a health plan needs to meet for accreditation:

Quality improvement

Utilization management

Credentialing and network development

Members' rights and responsibilities

Member connections

1. Which of these involves standards designed to ensure that the health plan promotes good medicine rather than acting in an arbitrary manner around patient care? Please explain

Answer 1

1.The National Committee for Quality assurance (NCQA) is a health plan accreditation body that must support care that keep members at optimum levels of health while and also controlling costs and meeting government and purchaser requirements.

It is a non-profit organization in the US.

The main purpose of the organization is to improve the quality of health care through measurement.transparency and accountability.

The standards are designed for the organizatons that are providing comprehensive mannaged behavioural health care services

They will evaluates the organizations providing comprehensive managed behavioural health care services

$\rightarrow$ Here coming to the NCQA standards of utilization management,where notifies the members and practitioners about the coverage decisions within required time frames.

The utilization management is the evaluation of medical necessity,appropriateness and the efficiency of the use of health care services,procedures,and facilities under the provisions of the applicable health benefit plan.

It may be sometimes called as utilization review

Through the Utilization management one can ensure the individual health plans and payor requirements

In the pharmacy utilization of the NCQA utilization management they use:

*Generic prescription rate

*Adherence rates as measured by timely refills

Appropriate pharmaceutical management can and does improve quality and may reduce other health care costs