Getting OnBoard Part 2
During: Earn It
The Recognition Process
All materials © 2014, National Committee for Quality Assurance
Start-to-Finish (S2F) Pathway
Your Roadmap to Recognition
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3 PHASES
• BEFORE: LEARN IT – Am I eligible? Can I make
the commitment? Why would I want to do this?
• DURING: EARN IT – I am committed what do I
need to do submit? What is required?
• AFTER: KEEP IT – I made it!
How do I keep my recognition?
What do I do if my practice changes?
How do I promote my achievement?
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“During/Earn It” Phase
The Nuts & Bolts of the Recognition Process
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First NCQA Software Used During the
Recognition Process
Online Application Account
• One account per organization handles many
applications, multiple sites. Used for PCMH (2011 &
2014), PCSP, CAHPS PCMH
• Enter primary contact, demographic practice and
clinician information
• Sign BAA and program agreement
• Resource library inside
• One application precedes every ISS survey tool
• Used to initiate Multi-Site approval
• Used to initiate Add-Ons
• Safeguard your user names and passwords
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Order free Online Application Account
www.ncqa.org/PublicationsProducts/RecognitionProducts.aspx
Organizations use the same
Online Application Account for
PPC-PCMH, PCMH, PCSP, and
CAHPS-PCMH
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Start-to-Finish
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What Are Multi-Site Surveys?
(PCMH & PCSP)
• Option for organizations or medical practices with 3 or
more sites that share policies and procedures and
electronic systems across all of their practice sites.
• NCQA does not give organization-wide Recognition
• A specified number of corporate (shared)
elements are completed once for
multiple practice sites in an additional
survey tool
• All other elements require responses at the site level
• Any possible multi-site should attend the “Getting on
Board” training for complete details
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What are Multi-Specialty Surveys?
(PSCP ONLY)
• Multi-Specialty organizations can be a single site
or Multi-site practice
• Both require NCQA approval
• Request approval teleconference through Online
Application
• Multi-specialty eligible practices will submit
examples from 3 or more specialties, including a
mental health specialty, if present for specified
elements
• Conference call will discuss submission of
individual specialty surveys versus multi-specialty
surveys
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During | Earn It
Start-to-Finish Step 8
Attend FREE Standards Training
“The Rules of the Program”
Free training each month
http://www.ncqa.org/tabid/109/Default.aspx
• PCMH & PCSP Standards (2 part program)
• Attend as often as you want
• Recorded version of PCMH 2014 (Coming Soon)
• Time to ask NCQA staff questions
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Transform Practice
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Transformational Prep Work
Start-to-Finish Step 9
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Assess practice site against Standards &
Guidelines
Document gap in performance and need for
written documentation
Write, finalize, and implement new procedures
Implement EMR
Build EMR data to support reporting requirements
Procedures and EMR must be in place for at least 3
months before initial submission
Anticipate at least 3 - 6 months prep time
Procedures and EMR must be fully implemented at
least 3 months before survey submission
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Now Prepare Your Submission
Start-to-Finish Steps 10-13
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Software Training
Start-to-Finish Step 10
Software Training
– Online Application
– Interactive Survey System (ISS) Tool
• Training is Recorded - Attend anytime!
•
http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/Recogniti
onTraining/PatientCenteredMedicalHomePatientCentered.aspx
• Not available as a live monthly training
• Demonstrates how to navigate and enter information into
the software
• Submit any questions or technical difficulties to assigned
technical analyst
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Buy ISS Survey Tools
Interactive Survey System Tool
http://www.ncqa.org/tabid/629/Default.aspx#
pcmh
• Survey tool purchase is the first of
2 payments to NCQA for each practice site
• Pay by check or credit card at $80 per
survey license
• Corporate and each site tool cost $80
• E-mail, fax, or mail printed order form with
payment
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Buy ISS Survey Tools
Interactive Survey System Tool
• Single site tools can be ordered on-line.
Multi-sites need preapproval
• 2 emails follow purchase acknowledging
purchase and providing username, password
and license number for each survey tool
purchased
• Order with the same practice name used in
application
• Manager and Analyst assigned after
purchase
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Complete Your Online Application
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Complete Your Online Application
Log in Online Application
Click new or continue
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Completing your Online Application
Sign the Agreements electronically
Create a separate application for each site
Enter your clinician data for each site
Note: Punctuation and spelling matter
Do NOT enter ALL CAPS
Link your clinicians to each application – which
clinicians are currently practicing at each site
• Enter the ISS license # from your e-mail
order for each site – creates a link
to the ISS tool
• Submit each site application to NCQA
• NCQA needs 5 business days to verify
site prior to accepting ISS tool
– NCQA will send you an e-mail
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Prepare and Submit ISS Tool
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NCQA Website: ISS Login
Access to Survey Tool
You can
always
access ISS
from
NCQA
Website
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Using the Survey Tool
Steps for the practice:
1. Organize supporting
documentation
2. Respond to ALL factors
3. Build document library
4. Link documents to elements
5. Complete Organizational
Background tabs
6. Review results
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Organize Supporting Documents
• Create a folder on the hard-drive for documents the
practice MAY want to attach
• Develop a checklist of documentation already used in
the practice and documents that need to be prepared
• Refer to standards and guidelines publication to
identify that the practice is providing the expected
documentation (see FAQs)
• No Protected Health Information
• Save a copy of the Record Review Workbook and
Quality Measurement and Improvement Worksheet
• NCQA advises a maximum of three (3) documents or
fewer per element (averaged – some require more,
others just one)
• Consider putting multiple documents in one document
for a single element in a logical order – tell your story
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Manage the Documents
Use a unique naming convention
• Use any organizing principle desired, for example:
– PCMH 1 A—Name of Document.docx
– PCMH 1 B—Name of Document.xlsx
• Avoid file names with special characters (e.g.
quotation marks, question marks, commas,
apostrophes, ampersands)
• Documents can be linked to multiple elements; no
duplicates should be in the Document Library
• Use text boxes and highlighting to identify important
sections and briefly explain the importance
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Respond to All Factors
Answer
EVERY radio
button even
if the answer
is No. If NA
make sure
to justify in
Text/Notes
area
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Build the Document Library
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Assemble documents in a PC file
No Protected Health Information
Assign meaningful file names
Highlight and label contents to draw reviewer
attention
Aim for 1- 3 attachments per element
Attach one document to several elements
Load up to 3 documents at a time into ISS Tool Library
and rename
Link documents to relevant elements
Save
Document changes require reloading
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Link Documents and Enter Text
for Explanations
Click here to link
documents
Click here to enter
explanatory text
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ISS Survey Tool Organizational
Background Tab
Inside the ISS
Survey Tool
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ISS Organizational Background Tab
Complete Practice Site Information
Attach more
information about
the practice. Give
it a face to our
reviewers.
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Complete Recognized Clinicians
•List the practice’s
clinicians with these
current Recognitions
for auto-credit:
•Diabetes
Recognition
Program
•Heart/Stroke
Recognition
Program
•Back Pain
Recognition
Program
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Pre-submission Completeness Check
• ISS Completeness Check Functionality
– Shows incomplete elements
– Multi-Site corporate tools will always show
incomplete elements
• Readiness of ISS Tool
– Check complete score and level
– Check Must Pass elements and critical factors
– Check that documents are linked to elements
• Verify Online Application was accepted, if not
an error message will appear when trying to
submit
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Reediness of ISS Tool Review
RESULTS:
 Summarized & Detailed
 Must Pass
 Critical Factors
 Meaningful Use
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Submit Program Fees and Surveys
Each practice site will have a separate application
fee based on the number of clinicians that see
patients at that site – this is the 2nd payment to NCQA
• Find current fees, check cover sheet and credit
card forms in Online Application payment tab
• Applicable fees are those current on the day of
submission
• NCQA will contact you if payment is not received
or correct when survey is submitted
• Survey review is not initiated until
full payment is confirmed
• No time limit on survey submission
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The Review Process
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Recognition Review Process
NCQA
• Checks licensure of all clinicians for restrictions
• Evaluates Survey Tool responses,
documentation, and explanations by
– Reviewer – initial evaluation
– Executive reviewer – NCQA PCMH managers
– Peer review – Recognition Program Review
Oversight Committee member (RP-ROC)
– Audit (5%) – by email, teleconference, or onsite audit
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Recognition Review Process
NCQA
• Issues final scoring decision and level to the
practice within 30 – 60 days by email
• Reports results
– Recognition posted on NCQA Web site
– Not passed - not reported
• Mails PCMH certificate and Recognition packet
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NCQA Evaluation: Example Text/Notes Entry
Reviewer Note
Practice Note
Justify all N/As
In Text/Notes
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Receive Recognition Decision
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Recognition Decisions
Recognition awarded at the practice site level
• Level 1, 2 and 3
• 3-year Recognition period
• Denial of Recognition
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PCMH score below 35 points
PCSP score below 25 points
One or more must pass elements <50%
Not made public or distributed to P4P
• Manager sends auto email to practice’s primary
contact
• Levels reported to public; scores are not made
public
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How to See Results in ISS
To view final
results, DON’T
open the
survey here.
Open the
survey here.
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NCQA Recognition Directory
Website Listing Includes:
 Clinician name, title (MD, DO, NP, PA)
 Practice name and address
 Current Recognition
 Recognition Program
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Certificates
Name of Practice
• Routinely sent within 3 weeks of Recognition
• Site-level
• Fee for replacements or additional certificates
• Request at http://ncqa.force.com/pcs/login select Certificates
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Start-to-Finish
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How to Request Approval
Login to the
Online
Application
Obtain an account
through the NCQA
website
Submit
Approval/Eligibility
Requests through the
Online Application
Choose the
account to work in
http://www.ncqa.org/Publication
sProducts/RecognitionProducts/P
CMHPublications.aspx
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How to Request Approval
Click to Submit a Multi-site
Approval Request
Answer the Eligibility
Questions
• NCQA sets up a teleconference with a Recognition Manager
within several days
• Preparation materials for the call are sent in advance
• Manager will explain corporate elements, submission process,
and answer any questions
• Last day to submit for PCMH 2011 Approval Calls is June 15
• First day to request PCMH 2014 Approval call June 1
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Approval Request
The system will ask
practice to wait for a call
from NCQA to schedule
your teleconference
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Conference Call Agenda
• Practice and NCQA must be on-line in the practice’s
Application
• NCQA’s Recognition Manager:
– Confirms Multi-Site eligibility
– Assesses organization’s ISS Tool naming convention
– Reviews Online Application process
– Explains potential Corporate and Site elements
– Confirms estimated timing of submissions
– Produces Multi-Site ISS Tool order form
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Approval Teleconference E-mail
When teleconference is
scheduled, practice
receives documents via
e-mail.
SEE NEXT SLIDES
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Approval Teleconference–Multi-Site
Process Overview
Detailed instructions
for getting the
application ready –
using the NCQA
naming convention
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Approval Teleconference
Multi-Site Fee Calculator
• Fee Calculator also found in Online Application Payment tab
• Multi-site fees are already discounted
• Corporate fee based on number of sites
• Site fee based on number of clinicians
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Print Order Form
After teleconference
this is where the
Online Application
can be found
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Multi-Site ISS Tool Order Form
Print Order Form from Online Account for approved
sites
• Designate which sites to order first
• Buy more ISS Survey Tools as needed
• Add future sites to the order form later
• Sites must be submitted within 12 months after
NCQA finalizes Corporate score
• NCQA Customer Support sells tools
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Print Order Form
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Multi-site Policies and Fees
• Submit “Order Form” to purchase the required
number of survey tools for the sites identified and
the corporate survey
• Clinicians can be listed at multiple sites
• Not all sites need to be included
• All sites must be submitted within 12 months of
receiving the corporate score
• Application fees are determined by site and based
on listed clinicians for each site along with a multisite review fee
• These areas will be covered in depth during the
approval teleconference
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What is the Multi-Site/Multi-Specialty Survey
Process?
1. An Online Application precedes each ISS
Survey Tool
2. Corporate ISS Tool is prepared and submitted
first
3. Corporate tool is scored within 30 days
4. NCQA will merge the score of the multi-site
survey with each site survey tool
5. Sites will receive Recognition decision within 60
days of submitting the site tools
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Corporate Elements
Elements below can be selected in corporate
survey tool:
1B
1C
2B
2C
3A
3B
3D*
3E
4D
4E
5A
5B*
5C
6A
6B
6C
6F
* Must
Pass
Elements selected for Multi-site Corporate Survey Tool,
must include:
• Data from largest site OR
• Aggregated data from all sites except 6A,B,C
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Select Corporate Elements
This is the PCMH 2014
ISS Corporate Survey
Tool Organizational
Background
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Prepare and Submit Site Tools
• NCQA copies Corporate elements into the
site tools
• Practice completes site tools and submits
• Site-specific tools must be submitted within
12 months of Corporate Tool score date
• Site tool turn around time target is 60 days
• Additional sites that share the same
systems, processes may be added and
submitted within the 12 month period
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NCQA Contact Information
Contact NCQA Customer Support at 1-888-275-7585
M-F, 8:30 a.m. - 5:00 p.m. ET to:
 Acquire standards documents, application account, survey tools
 Questions about your user ID, password, access
Visit NCQA Web Site at www.ncqa.org to:
 Follow the Start-to-Finish Pathway
 View Frequently Asked Questions
 View Recognition Programs Training Schedule
• For questions about interpretation of standards or
elements to submit a question to PCS (Policy/Program
Clarification Support)
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