Below are a few of the many items required for review

Analysis should be performed on all TPAs, PBMs, networks, network participating provider requirements, network reimbursement differentials as compare to Medicare reimbursements, direct contracting agreements, carve out programs, utilization review, concurrent review and any medical management programs. 

Essentially everything in the plan must be evaluated and documented in regard to NQTL. 

Some examples include:

  • Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative;
  • Prior authorization or ongoing authorization requirements;
  • Concurrent review standards;
  • Formulary design for prescription drugs;
  • For plans with multiple network tiers (such as preferred providers and participating providers), network tier design;
  • Standards for provider admission to participate in a network, including reimbursement rates;
  • Plan or issuer methods for determining usual, customary, and reasonable charges;
  • Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as “fail-first” policies or “ step therapy” protocols);
  • Exclusions of specific treatments for certain conditions;
  • Restrictions on applicable provider billing codes;
  • Standards for providing access to out-of-network providers;
  • Exclusions based on failure to complete a course of treatment; and
  • Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage.
  • ..And many more

Factors To Consider when evaluating NQTL

What was the strategy, process and evidence used to develop any NQTLs? 

A few factors might include:

  • Excessive Utilization;
  • Recent Medical cost escalation;
  • Provider discretion in determining diagnosis;
  • Lack of clinical efficiency of treatment or service;
  • High Variability in cost per episode of care;
  • High levels of variation in length of stay;
  • Lack of adherence to quality standards;
  • Claim types with high percentage of fraud;
  • Current and Projected demand for services;


Want to learn more?  Here is a great frequently asked questions list:

Frequently Asked Questions