FAQ Directory

NCQA strongly discourages using “Unknown” and “Two or More Races” response categories when collecting race and ethnicity data. When possible, organizations should instead use and encourage alternatives such as: 

• “Other” or “None of the above” response options for members who are unsure of their race or ethnicity. 

• The ability to select multiple race values for members with two or more races. 

If “Unknown” or “Two or More Races” are populated values in sources where health plans cannot improve response terms/options, they can be mapped to the “Some Other Race” reporting category. 

HEDIS 2023

The “Asked But No Answer” reporting category reflects members who were asked for race or ethnicity data, but who declined to provide a response. This reporting category must be attributed to a direct data source because the members self-reported by declining to answer.

HEDIS 2023

“Unknown” race and ethnicity values indicate missing data. Two criteria must be met to report “Unknown”: 

1. There is no recorded value, and  

2. The organization did not receive a declined response from the member. 

Starting in MY 2023, all “Unknown” values must be attributed to an unknown data source. This is a change from MY 2022, when “Unknown” values were attributed to an indirect data source.   

HEDIS 2023

No. Volume 5: HEDIS Compliance Audit MY 2023 does not include new requirements for reporting race and ethnicity. Consistent with MY 2022, these data are addressed in the HEDIS Roadmap. Auditors must confirm that organizations provide a complete Roadmap response, and review all attachments describing data flow, layout and transformation. Roadmap Section 6, Question 6.3J requires organizations to describe the sources they use, their processes for disaggregating race and ethnicity fields, their data source reconciliation and prioritization processes and the percentage of members with available data.  

NCQA introduced a direct data threshold of ≥20% for Race/Ethnicity Diversity of Membership (RDM) in the 2024 Health Plan Ratings scoring methodology. Please note that this is independent from the race and ethnicity stratifications, and should not impact audit designations. There are no bias thresholds for the race and ethnicity stratifications in Volume 5.

HEDIS 2023

No. Codes to identify race and ethnicity resemble some LOINC codes (i.e., the same format), but are derived from a code system developed by the U.S. Centers for Disease Control and Prevention (CDC).
The code is the same across terminologies in multiple instances. NCQA recommends that organizations establish data quality controls to avoid inadvertent data reporting errors. For example, “2106-3” could result in errors if used incorrectly:

• 2106-3 = “White” (CDC Race and Ethnicity).
• 2106-3 = “Choriogonadotropin (pregnancy test) [Presence] in Urine” (LOINC).

HEDIS 2024

It depends:

• For data streams provided by aggregators with a current approved validation status in the NCQA Data Aggregator Validation program, only Roadmap Section 5 from the plan is required. 
• For all other data streams provided by aggregators that are not validated in the DAV program, a Roadmap Section 5 from the plan and Section 5a from the aggregator are required.

NCQA maintains an online directory of entities with validated data streams.

HEDIS 2024

No. Notice of Medicare Non-Coverage (NOMNC) denial files are out of NCQA’s scope of review and should be excluded from the UM file universe.

HP 2024

Yes. Organizations may use SAM.gov to verify Medicare and Medicaid sanctions for CR 3, Element B, factor 2 and CR 5, Element A, factor 1.

HP 2024

Yes. Organizations may use SAM.gov to verify Medicare and Medicaid sanctions for CVO 11, Element A and CVO 14, Element C.

CVO 2022

Yes. We anticipate the laboratory claim exclusion will be added to the following measures and value sets in the Technical Update memo:
AMR:    Step 2 of the event/diagnosis (Asthma Value Set)
GSD:    Numerators (HbA1c Test Result or Finding Value Set)
EED:     Event/diagnosis (Diabetes Value Set)
OMW:   Step 2 of the event/diagnosis (Fractures Value Set)
SSD:     Numerator (HbA1c Test Result or Finding Value Set)
SMD:    Numerator (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
SMC:    Numerator (LDL-C Test Result or Finding Value Set)
IET:      Step 2 of the event/diagnosis (Alcohol Abuse and Dependence Value Set; Opioid Abuse and Dependence Value Set; Other Drug Abuse and Dependence Value Set)
APM-E: Numerators (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
DSF-E:  Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Depression Value Set)
DMS-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
DRR-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
ASF-E: Exclusions 1 (Alcohol Use Disorder Value Set; Dementia Value Set)

HEDIS 2024

When reporting CCS-E, all three methods may be used, using any data source. When reporting CCS, use only administrative data (Administrative Gender of Female [AdministrativeGender code F] any time in the member’s history) to determine members recommended for routine cervical cancer screening.
Where supplemental data may be used for CCS remains the same for MY 2024. Supplemental data may not be used for denominator criteria, except in required exclusions.

HEDIS 2024

Although HEDIS digital measure logic references “Explanation of Benefit (EOB),” this is not referenced as a data source in HEDIS Volume 2. In FHIR, the EOB resource represents claims that have been adjudicated, and includes data elements from both Claim and ClaimResponse. The digital logic was written to include the Claim/ClaimResponse resource for claims that are still processing; the ExplanationOfBenefit resource is for claims that are adjudicated.

HEDIS 2024