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Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can  ask a question through My NCQA.

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4.14.2017 Comprehensive Diabetes Care Please clarify the instruction to not include BP readings taken on the same day as a diagnostic test or procedure that requires a change in diet or medication. Must the change in diet or medication be required by the procedure? Is the BP eligible if a patient forgets to take their regular medication the day of a procedure? Is the BP eligible if the member receives a vaccine, a nebulizer treatment with albuterol or lidocaine injected prior to an unplanned removal of a small mole?

The intent is to identify diagnostic or therapeutic procedures that require a medication regimen, a change in diet or a change in medication. For example, colonoscopy requires a change in diet (NPO on the day of procedure) and a medication change (a medication is taken to prep the colon). Dialysis, infusions and chemotherapy are all therapeutic procedures that require a medication regimen. A nebulizer treatment with albuterol is considered a therapeutic procedure that requires a medication regimen (the albuterol). Injection of lidocaine prior to mole removal is considered a diagnostic procedure (if the mole is being tested) or a therapeutic procedure (if removal of the mole is the treatment) that requires a change in medication (lidocaine administered for pain control during the procedure). A patient forgetting to take regular medications on the day of the procedure is not considered a required change in medication, and therefore the BP reading is eligible.

 A BP taken on the same day that the patient receives a vaccination is eligible for use. A vaccination is considered preventive medicine and is not considered a therapeutic or diagnostic procedure.

HEDIS 2017

3.15.2017 UM 9 C: Scoring reviewer for appeals of system-made benefit denials Under UM 9, Element C, for an appeal of an initial benefit denial that was made by an automated system (e.g., claims or POS), where a person makes the appeal decision, should the file be scored “NA” or “Yes”?

The file should be scored "Yes.” A person making the appeal decision is different from, and not subordinate to, an automated system.

HP 2017

2.15.2017 Effective date for Case Management Accreditation 2017 and Termination date of Case Management Accreditation 2014 When will the 2017 CM standards be effective and when will the 2014 CM standards year end?

The 2017 CM standards are effective on or after January 30, 2017. For organizations that have already scheduled a survey through June 30, the 2014 CM standards year will end on June 30, 2017. 

CM 2014

2.15.2017 Adolescent Well-Care Visits Does documentation of “Tanner stage” meet criteria for the physical exam or physical developmental history component for the Adolescent Well-Care Visits (AWC) measure?

Yes. Documentation of Tanner stage meets criteria for the physical exam and physical developmental components, but should not be double-counted toward both (if used as evidence of physical exam, it may not be used as evidence of physical developmental, and vice versa). Documentation of Tanner stage does not meet criteria for the Well-Child Visits in the First 15 Months of Life (W15) or Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) measures as sexual maturity rating is not recommended until 7 years of age.

HEDIS 2017

2.15.2017 Standardized Healthcare-Associated Infection Ratio When reporting the columns “Percentage of Total Discharges From Hospitals With Unavailable SIR,” “Number of Contracted Hospitals With Reportable SIR” and “Total Inpatient Discharges” in Table HAI-1/2/3, if a hospital is not listed in Table HSIR, is it included in the count?

Hospitals for which plans have discharges from but are not identifiable in Table HSIR should not be included in the hospitals reported in the category "Number of Contracted Hospitals With Reportable SIR." However, discharges from these hospitals should be included in “Total Inpatient Discharges” and in “Percentage of Total Discharges From Hospitals With Unavailable SIR.” Use Table HSIR posted on the NCQA Web site to make the determination; organizations do not need to refer to the Hospital Compare web site.

HEDIS 2017

2.15.2017 Standardized Healthcare-Associated Infection Ratio In Table HAI-1/2/3, the four columns labeled “Percentage of Total Discharges From ...”. are collected in IDSS using 4 digits after the decimal. Because the columns are percentages, how should the data for these columns be displayed? For example, using HAI-1: Central line associated blood stream infection (CLABSI), if there are 100 contracted hospitals, of which 10 belong to “high” category of Standard Infection Ratio, what should the reported value be?
A) 0.1000
B) 10.0000

Option A. Organizations should report results as a decimal; therefore, option A is correct when reporting in IDSS. IDSS will include a validation that checks for values to be reported between 0 and 1 and must be rounded to 4 decimal places.

HEDIS 2017

2.13.2017 Proportion of Days Covered by Medications (PDC) Are the PDC denominator exclusions required, or optional?

All PDC denominator exclusions are required if the data are available.

IHA 2016

2.13.2017 General Guidelines Should the Value Based P4P General Guideline 19: Members in Hospice guideline apply to all clinical measures? The note that appears in most measures referencing this exclusion and guideline does not appear in the ENRST, PDC or HRM measures.

Yes. Value Based P4P General Guideline 19: Members in Hospice should apply to all clinical measures, including ENRST, PDC and HRM. We will add a note to all clinical measure specifications for the next release of the manual.  

IHA 2016

2.13.2017 Advancing Care Information (ACI) Domain The note on page 143 of the MY 2016 Value Based P4P Manual states: Include all payer types in e-Measure reporting; do not limit to commercial HMO/POS.
For each e-measure, should the patient-level numerator and denominators (Rate 2: PO-level aggregated performance) be limited to the managed care population only, or include all members?

The Value Based P4P program intends to measure all commercial HMO/POS members, but we understand that not all POs can limit their numerators and denominators to specific product lines. For this reason, and because VBP4P is not currently scoring the PO-level aggregated performance, POs may include all payer types. If the PO has the ability to limit the patient population to just commercial HMO/POS, that is also accepted.

IHA 2016

2.13.2017 Advancing Care Information (ACI) Domain Our PO does not have an integrated EHR system, and some of our providers may have contracts with other POs. For each e-measure, should the patient level numerator and denominators (Rate 2: PO-level aggregated performance) be limited to our PO’s members only, or include all patients for the provider?

Based on the potential burden of reporting PO-specific membership and because VBP4P is not currently scoring the PO-level aggregated performance rate, POs may include all patients for the provider. If the provider has the ability to only include the PO’s members, that is also accepted.

IHA 2016

1.15.2017 UM 7 B: Specific criterion referenced in a denial decision In UM 7, Element B, factor 2, organizations are required to reference the specific criterion used to make a denial decision. How specific does the criterion need to be?

The criterion referenced must be identifiable by name and must be specific to an organization or source (e.g., ABC PBM’s Criteria for Treatment of Hypothyroidism with Synthroid or CriteriaCompany Inc.’s Guidelines for Wound Treatment). If it is clear that the criterion is attributable to the organization, it is acceptable to state “our Criteria for XXX” (e.g., our Criteria for Treating High Cholesterol with Lipitor).

Note: This also applies to Element E and Element H in HPA and Element E in UM-CR.

HP 2016

1.15.2017 Reporting the Aspirin Use and Discussion measure for HEDIS 2017 Will NCQA collect or report results for the Aspirin Use and Discussion measure for HEDIS 2017?

No. NCQA has decided to retire the Aspirin Use and Discussion (ASP) measure due to misalignment with updated recommendations from the United States Preventive Services Task Force (USPSTF). The updated USPSTF aspirin recommendations include a calculation of 10-year cardiovascular risk and an estimate of 10-year life expectancy. This information would be required to identify the denominator of the ASP measure and because it cannot be captured in the Consumer Assessment of Healthcare Providers & Systems (CAHPS) Health Plan Survey or claims data, we are unable to adapt the measure to be consistent with the USPSTF findings.

 

The aspirin questions remain in the HEDIS 2017 CAHPS questionnaire but member responses to the questions will not be submitted to NCQA by the certified survey vendor. The questions will be removed from the HEDIS 2018 CAHPS questionnaire.

HEDIS 2017