What is NCQA?

The National Committee for Quality Assurance (NCQA) "is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans." and "is governed by a Board of Directors that includes employers, consumer and labor representatives, health plans, quality experts, and representatives from organized medicine." NCQA can be reached on the net at .

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Who regulates health care plans in California?

The Department of Managed Health Care (DMHC), through laws enacted by the California State Legislature, has responsibility for licensing and regulating health care service plans. The DMHC can be reached at (888) HMO-2219 or on the net at and .

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How does an IPA fit into the health care system?

An Independent Practitioner Association (IPA) provides the link between health plans (HMO's, etc) and providers of medical services. In general, the IPA pays the providers for services given to health plan members, identifies patients eligible for services, ensures compliance with governmental, health plan, and accrediting body guidelines, resolves complaints and a lot more.

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What is a KNOX-KEENE license?

A Knox-Keene license is currently granted by the California Department of Managed Health Care (DMHC) to health care service plans or specialized health care service plans. The license is issued pursuant to Section 1353 of the Knox-Keene Health Care Service Plan Act of 1975 as amended. This license ensures that these organizations meet certain minimum standards and gives them the right to conduct business in the state of California.

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Who is CMS?

The Centers for Medicare & Medicaid Services [formerly known as Health Care Financing Administration (HCFA)] is part of the United States government Department of Health and Human Services. The agency is charged with the responsibility to administer the laws, regulations and issuance of manuals related to Medicare and Medicaid. The CMS web site is at .

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Who or what is a PCP?

A PCP is your primary care physician, the first person to contact for medical assistance. Your PCP manages your routine health care needs and will refer you to a specialist if the needed medical treatment is outside his/her field of expertise. PCP's are usually trained in family practice, general practice, internal medicine, or pediatrics. In many health care plans, an OB/GYN may also qualify to be a PCP.

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I’m a member of a managed care plan and my doctor said I need a referral. It’s been two or three weeks and “nobody has approved it” yet? What do I do?

First, check with your doctor’s office to see what the delay is. More information may have been needed to make a determination. Or, your referral request may have been one that was “lost” somewhere in the process. (Yes, it can sometimes happen.)

Second, there are time standards most managed care organizations must meet when reviewing routine and urgent referral requests. Check with your organization’s member service representative and ask what they are. Ask the representative to follow up on your request and get back to you with the status. If you have been dealing with an IPA or medical group and the situation remains unresolved, call your health plan.

Third, don’t be afraid to let your doctor know that your referral approval is outside of the standards, and you want it expedited.

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What does it mean if my health plan has been accredited by NCQA? Why is accreditation or certification important?

Accreditation organizations evaluate one or more areas of a health care entity’s operational processes, organizational structure, medical management procedures, member service practices, quality improvement activities, etc. Accreditation or certification means that the entity has passed a rigorous review and has the necessary processes, structure, and administration in place to promote/provide quality care and protect patient rights. Accreditation or certification can be focused on one or more specific areas (e.g. provider credentialing or utilization management) or it can cover all of the organization’s major operations.

Many types of health care organizations can be accredited or certified. These can include: managed care plans (HMO, PPO, POS), physician organizations (IPAs or medical groups), physician/hospital organizations (PHO), and others.

In addition to NCQA there are other organizations (JCAHO and American Accreditation HealthCare Commission/URAC are examples of two others) that evaluate health care organizations. There are also specialized certification or accreditation programs that evaluate entities such as skilled nursing facilities, laboratories, ambulatory surgical facilities, etc.

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I have heard many of the following terms and wonder what they mean: clinical criteria, practice guidelines, treatment protocols, clinical practice guidelines, and utilization management (UM) review criteria?

Clinical criteria, practice guidelines, treatment protocols, and clinical practice guidelines are terms that can generally be used interchangeably. These terms describe a set of tools (narrative descriptions or standard set of care specifications) used to help practitioners and patients make decisions about appropriate health care for specific clinical circumstances. Practice guidelines are based on professionally recognized standards and usually systemically developed through a formal process. They are developed with input from practitioners and based on authoritative sources including clinical literature, studies, and expert consensus.

UM review criteria is often confused with the clinical practice guidelines or treatment protocol terminology. UM review criteria are a set of criteria used by medical management staff in a managed care or health insurance organization. The criteria are used to evaluate whether a requested service is appropriate for the diagnosis and if it will be covered under the member’s health care coverage. These are the “tools” used when your provider submits a service to a health care organization for “prior authorization” review.

UM review criteria are not considered guidelines that direct a practitioner “how” a specific problem should be treated. UM review criteria are frequently developed utilizing clinical practice guidelines as their foundation

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What are member rights and responsibilities?

Member rights and responsibilities is a document frequently given to members of managed care organizations as part of their membership. It lists the rights you have as a member of the plan and the responsibilities you have in complying with the plan’s requirements.


Member right - “you have the right to be treated with respect”.

Member responsibility - “you are responsible to pay your co-payments when you visit your doctor”.

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What do I do in an emergency?

Whenever you have a true emergency, call 911 or go directly to the nearest emergency care facility. Otherwise, call your primary physician and follow his/her instructions.

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How do I know if it is an emergency that will be covered by my health care coverage?

The following definition comes from the Code of Federal Regulations and is used in the Medicare and Medicaid programs. This definition or similar definitions are also included in many state laws. These federal definitions (or a variation) have also been adopted for use by many commercial health plans and insurers.

An emergency condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

1. Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child;

2. Serious impairment to bodily functions; or

3. Serious dysfunction of any bodily organ or part.

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As a self employed small business owner, how can I get healthcare coverage?

1. If you are a member of a professional organization, check with them. Many organizations provide group rates and discounts.

2. Also there are national associations for self-employed individuals or small business owners. Check the internet for trade associations under which your business might fall.

3. Some states have regulations allowing small business owners to obtain insurance under "small group" rates through a health insurance purchasing pool. Check the state website under insurance or health care listings.

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