Medicaid Managed Care - U.S. Senate Special Committee on Aging

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ual practitioners who work in such agencies, instead of contracting with
the agency itself as a provider, except in limited circumstances (see CR
12 below). This can have an adverse impact both on the agency, which
must bill in more complex ways, and for plan members, who may not
have access to some of the agency's services.
Public purchasers should include in contracts specific provisions
that override the limited NCQA credentialing process and replace it
with standards tailored to the state's system.
b) Written Policies and Procedures (CR I)
The NCQA standards reference specialists 'registered by the state.'
Public payors may wish to use this standard in order to build a complete
list of the programs and traditional and non-traditional providers
with whom the plan is expected to contract. Otherwise, the NCQA
standards on credentialing may prose a barrier to good care in the public
sector (see above).
c) Credentiating <strong>Committee</strong>
Credentialing committees should include representatives of all peer
groups, including non-traditional providers. Public payors may also
wish to require inclusion of representatives of plan members, family
groups or advocacy organizations on such committees, at least in an advisory
capacity.
d) Credentialing Process (CR 3, CR 4, CR 5)
All of these standards regarding credentialing will need to be
strengthened in order to accommodate appropriately the need for nontraditional
providers.
e) Organizational Providers (CR 12)
NCQA includes a category of organizational providers with whom
a managed care entity can contract for all of the organization's costs in
providing services. However, the NCQA standards' examples of organizational
providers is narrow. Public payors should consider expanding
the list to include all appropriate community-based agencies and providers
from other systems (schools, etc.) as appropriate.
NCQA Accreditation Standards for <strong>Managed</strong> Behavioral Healthcare Organizations
POLICY ANALYSIS BY THE BAZELON CENTER FOR MENTAL HEALTH LAW
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