Table RDI-B-4 should include all 13 risk groups, to match the RRU General Guidelines in the QRS technical specifications.
Exchange 2015
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2.26.2015 Relative Resource Use for People With Diabetes In the Quality Ratings System (QRS) Measure Technical Specifications, the RRU General Guidelines reference 13 risk groups, but there are only 8 risk groups referenced in Table RDI-B-4: Data Elements for Relative Resource Use for People With Diabetes. Which is correct?
2.17.2015 Evidence Based Cervical Cancer Screening (ECS) The service date example in Rate 2, step 2 states, “If the service date for cervical cytology was November 27 of the measurement year, the HPV test must include a service date on or between December 1 and December 5 of the measurement year.” This does not align with the other service data examples in Rate 1 and Rate 3 of the Administrative Specifications. Should the service dates in Rate 2, step 2 align with the other examples?
Yes. The service date example in Rate 2, step 2 should align with the examples in Rate 1 and Rate 3. The dates were inadvertently switched in the Rate 2 example and should state:
“For example, if the service date for cervical cytology was December 1 of the measurement year, the HPV test must include a service date on or between November 27 and December 5 of the measurement year.”
IHA 2014
2.17.2015 Proportion of Days Covered by Medications (PDC) The ESRD Value Set includes the code RxHCC 121. Is the RxHCC code system new? Where is this type of code found?
Yes, the RxHCC code system and code were added to the Value Set Directory when we created the ESRD Status Value Set. This code is used to identify patients with ESRD for the denominator exclusion in Diabetes: Appropriate Treatment for Hypertension and Proportion of Days Covered by Medications.
The RxHCC code can be found in the CMS Medicare Advantage and Prescription Drug System (MARx), which provides a monthly report of members’ RxHCCs to plan sponsors. For MY 2014, use the 2013 model software of the RxHCC system.
IHA 2014
2.17.2015 Proportion of Days Covered by Medications (PDC) The DTX and PDC measures include a denominator exclusion for ESRD status. Does the status need to be “any time in the member's history,” or just during the measurement year?
2.17.2015 Controlling High Blood Pressure for People with Hypertension (CBPH) In the Controlling High Blood Pressure for People with Hypertension specifications, there are three rates in the description. In the clinical file layouts, only one rate is included. Is this intentional?
No. The two additional rates were inadvertently left out of the clinical file layouts. Three rates should be reported for this measure:
- The percentage of non-diabetic members 18-59 years with a diagnosis of hypertension whose blood pressure was adequately controlled (<140/90 mm Hg) during the measurement year.
- The percentage of non-diabetic members 60-85 years with a diagnosis of hypertension whose blood pressure was adequately controlled (<150/90 mm Hg) during the measurement year.
- The total rate.
Revised Clinical File Layouts have been posted for health plans and physician organizations (http://iha.org/manuals_operations_2014.html), to reflect this change.
IHA 2014
2.15.2015 Data that meets annual data collection and analysis requirements If an organization is surveyed less than a year after beginning operations, how does it meet elements that require annual data collection and analysis?
NCQA does not require the organization to collect and analyze a full year of data. For First Surveys, the look-back period is “at least once within the past year” for elements requiring annual data collection and analysis. The requirement is met if an organization collects and analyzes the data within a year of submitting the Survey Tool.
2.15.2015 Negative inferences of stating quality, experience or cost is not measured for practitioners and hospitials For QI 12, Element A, factor 3 and Element B, factor 2, did NCQA consider the negative inference of requiring an organization to state that it does not use quality, member experience or cost-related measures when selecting practitioners or hospitals to participate in its network?
Yes. The intent of this requirement is to provide consumers with quality information about Marketplace Silver Plans in order to help them make a better informed choice during enrollment. Therefore, organizations to be transparent about whether they used quality, member experience or cost-related measures when selecting practitioners or hospitals to participate in its networks.
2.15.2015 Use of credentialing and recredentialing verification to meet factor 3 For QI 12, Element A, factor 3, do verification activities conducted during the initial credentialing and recredentialing process count as quality measures?
CR 3–CR 6, credentialing verification activities do not count as quality measures for QI 12, Elements A and B. However, an organization may receive credit if its credentialing process incorporates clinical quality measures from NCQA (or other accreditors), the National Quality Forum (NQF), national medical boards (ABMS or AOA) or other quality measurement development sources. The organization may also incorporate member experience and cost-related measures into the credentialing process.
2.15.2015 Meeting factor 3 for Marketplace POS products Our organization provides a point-of-service (POS) product, where members may access out-of-network services without requesting authorization or obtaining a referral. Are we required to meet QI 12, Element C, factor 3?
The intent of QI 12, Element C, factor 3 is that the organization collects data to understand how out-of-network services are used, whether or not members must make a formal request to use them. Therefore, NCQA considers “request for” and “use of” to be interchangeable terms. For POS products where members are not required to obtain authorization, the organization may use claims data, UM data (e.g., post-service request) or similar data.
2.15.2015 Meeting factor 3 for organizations with a single network for Marketplace and non-Marketplace product lines If an organization has a single network for Marketplace and non-Marketplace product lines and has a single practitioner directory that does not delineate practitioners by product line, for QI 12, Element A, factor 3, must the practitioner directory state that the organization does not use quality, member experience or cost-related measures when selecting practitioners?
Yes. QI 12, Element A applies even if all practitioners are available to all product lines. To receive credit, the organization’s directory must state that the organization does not use quality, member experience or cost-related measures when selecting practitioners to participate in its Marketplace Silver Plan.
2.15.2015 Meeting factor 3 for staff and group model health plans Does QI 12, Element A, factor 3 apply to organizations that contract exclusively with a staff model or group model as an identical network for all product lines?
2.15.2015 Web site linking requirement to meet factor 4 To meet RR 4, Element E, factor 4, are organizations required to link to specific hospital data or may they link to the general quality data landing page on a recognized source Web site?
The hospital directory must contain quality data from recognized national or state sources, or a link to recognized-source quality data specific to each hospital, if the link exists. If linking to the data is not technically possible (e.g., because of a requirement to accept terms of agreement), a link to the quality data landing page is acceptable. A link to the source’s general Web site home page does not meet the requirement.