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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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11.15.2013 General Guidelines If a member is included in a measure's denominator due to an incorrect code, may a corrected claim be submitted to remove the member from the measure?

It is not NCQA's policy to dictate an organization's claims submission process. Claims may be corrected or updated as necessary before the HEDIS reporting process begins. However, once the HEDIS reporting process has begun (i.e., the measures' eligible populations are identified and samples are drawn for hybrid reporting), the requirements specified in Volume 2 General Guidelines and Technical Specifications must be followed.

For administrative-only measures, members who meet the eligible population criteria for the measure should remain in the measure. If an organization refreshes data for administrative-only measures, the most accurate and current information must be used for reporting. Additionally, the organization must apply the refresh to all applicable measures.

For hybrid measures, members who are in the denominator due to inaccurate claims data may meet criteria for a valid data error. Valid data errors are identified only for hybrid measures during medical record review and may not be identified using supplemental data. In order to categorize a member as a valid data error (and replace the member with another member from the sample), the chart must show no evidence of the diagnosis and must include evidence to explain or substantiate the data error. As described in General Guideline 40, organizations that elect to refresh data for the sample may not use the refreshed data to change the hybrid sample after it has been selected. The auditor reviews all valid data error exclusions during Medical Record Review Validation.

HEDIS 2014

11.15.2013 Initiation and Engagement of Alcohol and Other Drug DependenceTreatment The list of code combinations to identify Initiation and Engagement visits do not include codes to identify inpatient admissions. Do inpatient admissions count as initiation and engagement of AOD treatment?

As stated in the paragraphs prior to the list of code combinations, an inpatient admission with a diagnosis of AOD meets criteria for both initiation and engagement. Because NCQA does not specify codes to identify inpatient admissions, inpatient admissions were not included in the list of code combinations. The lists of code combinations include only visits for which value sets exist (outpatient, intensive outpatient and partial hospitalization). Organizations should use their own methods for identifying inpatient admissions when identifying initiation and engagement visits.

HEDIS 2014

11.15.2013 Value Set Directory The Summary of Changes spreadsheet in the HEDIS 2014 Volume 2 Value Set Directory lists LOINC code 72732-0 as added to the Sexual Activity Value Set, but that code is not in the Volume 2 Value Sets to Codes spreadsheet.

LOINC code 73732-0 was added to the Sexual Activity Value Set; it was entered incorrectly (as 72732-0) in the Summary of Changes spreadsheet. We apologize for the inconvenience.

HEDIS 2014

11.15.2013 General Guidelines Have the dates been extended for primary source verification (PSV) and final approval of supplemental data for HEDIS 2014?

Yes. Data collection and entry of all nonstandard and member-reported supplemental data must stop on March 3. PSV and final approval must be completed by March 14, for member-reported supplemental data, and by March 28, for nonstandard supplemental data. PSV may not occur before March 3 unless all supplemental data processes, collection and entry have stopped. Supplemental data approval and PSV may not occur, under any circumstances, before January 1 and receipt of the Roadmap.

HEDIS 2014

11.15.2013 Practitioners listed in the directory that require credentialing Are practitioners listed in the directory within the scope of credentialing?

Yes. Practitioners listed in the organization directory must be credentialed.

11.15.2013 Scoring Cervical Cancer Screening in 2014 How will organizations be scored on the Cervical Cancer Screening (CCS) measure for HEDIS 2014 reporting?

All organizations will be scored NA for 2014 reporting due to significant specification changes. However, the NA will not count against the eight NA thresholds used to covert to Standards plus CAHPS or Standards Only scoring.

11.15.2013 Effective dates of specificity requirements in Delegation Agreements For Element A in all standard categories in delegation (QI 12, UM 15, CR 9, RR 7, MEM 9), will existing delegation agreements be grandfathered if they do not meet the specificity required in the 2014 Written Delegation Agreement elements?

No. All existing delegation documents must be modified to reflect the specificity requirements before January 1, 2015. All new delegation documents that were effective on or after October 1, 2013, must meet the specificity requirement for standard year 2014.

11.15.2013 Information required in HA disclosures Is the organization required to explain how it assesses member understanding in the health appraisal under MEM 1, Element B, factor 4?

No. Such a statement is not needed in the health appraisal, although the organization is required to have a process for assessing member understanding of the information required by factors 1_3. For factor 4, NCQA reviews the organization's documented process for evaluating understandability of HA disclosures.

11.15.2013 Routine dental and vision care under medical benefit For UM and CR, are routine dental and vision care considered part of the medical benefit for the Exchange product line?

No. Although routine dental and vision care are included as essential benefits as part of the Affordable Care Act, NCQA was approved for its current requirements as an accrediting organization for Exchanges. Because routine dental and vision care are not included in the benefit requirements or utilization management, we will not survey them for 2013 and 2014 health plan accreditation.

10.15.2013 Meeting UM 7C and 7F using the Notice of Denial of Medical Prescription Drug Coverage. Does the Notice of Denial of Medicare Prescription Drug Coverage meet the same factors in UM 7, Elements C and F as the Notice of Denial of Medical Coverage (NDMC)?

Yes. NCQA accepts the Notice of Denial of Medical Prescription Drug Coverage as meeting factors 1-3 of these elements.

UM-CR 2013

10.15.2013 Commercial and Medicare Exchanges. Do private commercial and Medicare exchanges come under the Exchange product line?

No. The Exchange product line is only for the public (ACA-related) exchanges. Private commercial exchanges come under the commercial product line and Medicare exchanges come under the Medicare product line.

10.15.2013 Use of a vendor or delegate for HIP and WHP Certifications. May an organization coming through for HIP or WHP certification use a vendor or delegate for any functions or activities required by the standards and guidelines?

No. Organizations coming through for NCQA HIP or WHP Certification may not use a vendor or delegate for any functions or activities required by the HIP/WHP certification standards and guidelines.

WHP 2013