FAQ Directory

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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5.16.2013 General Guidelines Does an ICD-9 code of "411" mean that only code "411" is to be used, or do we also include all successor codes: 411.0, 411.1, 411.81, 411.89?

Unless otherwise noted, codes are stated in the minimum specificity required. For example, if a three-digit code is listed, it is valid as a three-, four- or five-digit code. If a table lists ICD-9-CM Diagnosis code 401, the codes 401.0, 401.1 and 401.9 are acceptable for P4P reporting. When required, a code will be specified with an x, which represents a valid digit that must be used for reporting. For example, ICD-9-CM diagnosis code 640.x1 indicates that any valid fourth digit can be used if the fifth digit is 1.

This applies to the following Programs and Years:

5.15.2013 Monitoring Medicare Opt-Out Physicians May MA organizations use NPDB-HIPDB as a source of information for Medicare opt-out physicians?

No. The NPDB-HIPDB may not be used as a source for verifying a practitioner's status in relation to the Medicare Opt-Out Program. MA organizations can check with their states' Medicare Opt-Out list.

This applies to the following Programs and Years:
MA 2013

5.15.2013 Pay-for-performance Program If our organization displays information about our pay-for-performance program but does not display physician performance information for this program, how does NCQA score PQ 3A, 3B, 3C, 3D and 4B?

PQ 3A factors 3-5 and PQ 3B are scored NA if the organization does not display physician performance information for the pay-for-performance program.

PQ 3 C and D are scored against the pay-for-performance requirements if the organization has one complaint process for all programs. If the organizations complaint process is program-specific, PQ 3C and D are scored NA for the pay-for-performance program. NCQA scores PQ 4B factor 1 and the customer portion of factor 4 NA for the pay-for-performance program.

Because there is no NA scoring option in PQ 3B, 3C and 4B, these requirements are scored yes for pay-for-performance programs described above until the NA scoring option is added during the 7/29 release of the ISS tool.

This applies to the following Programs and Years:
PHQ 2013

5.15.2013 When ER files are included in the universe of files for review When are ER denial files included in the universe of files for file review during an Accreditation or Certification Survey?

Generally, ER denials are not included in the universe of files for initial UM decisions unless a denial is appealed. In that case, the ER appeal is included in the universe of files for appeals.

This applies to the following Programs and Years:
UM-CR 2013

5.15.2013 National Student Clearinghouse as a source for education and training Does NCQA accept the National Student Clearinghouse (NSC) as a source for education and training?

The NSC is not recognized by NCQA as a source for education and training. However, the NSC would be considered an agent of the medical or professional school if the school has a contract with the Clearinghouse to provide verification services. The organization must provide documentation that the specific school has a contract with the Clearinghouse.

This applies to the following Programs and Years:
UM-CR 2013

4.16.2013 Proportion of Days Covered (PDC) The specification requires a pharmacy benefit, but does not require a medical benefit. How do we identify and attribute members with only a pharmacy benefit?

Members with only a pharmacy benefit are not attributed to a PO, so they are not included in the measure.

This applies to the following Programs and Years:

4.16.2013 Proportion of Days Covered (PDC) The specifications require a pharmacy benefit, but POs do not have access to pharmacy benefit information. How do we verify that a member has a pharmacy benefit, and the start and end dates for that benefit?

If a PO receives pharmacy claims for a member, it can assume that the member has a pharmacy benefit, and that the pharmacy benefit dates align with the medical benefit dates.

This applies to the following Programs and Years:

4.16.2013 Adult BMI Assessment (ABA) The specifications state that ABA is the same measure as the CMS Stars measure Adult BMI assessment, which uses the HEDIS specification. The HEDIS specification defines continuous enrollment as the measurement year and the year prior, but the IHA specification defines continuous enrollment as only the measurement year. Which is the correct continuous enrollment?

The continuous enrollment should be the measurement year and the year prior to the measurement year. This will be corrected in the MY 2013 version of the P4P manual.

This applies to the following Programs and Years:

4.16.2013 Proportion of Days Covered (PDC) The measure specification does not have an anchor date. How do we attribute members without an anchor date?

The Index Prescription Date (IPD) can be used as the anchor date.

This applies to the following Programs and Years:

4.16.2013 Diabetes Care (CDC) The following note appears to be listed under the Optimal Diabetes Care indicator for CDC: Additional exclusion criteria are required for this indicate that will results in a different eligible population from all other indicators. What are the additional criteria for the Optimal Diabetes Care indicator?

This footnote is meant to refer to the HbA1c<7% indicator; HbA1c<7% is the only CDC indicator that has a different eligible population from the other indicators. The footnote will be correctly placed in the MY2013 P4P Manual.

This applies to the following Programs and Years:

4.16.2013 Asthma Medication Ration (AMR) Table AMR-C includes the drug Indacteral, but this drug is not the final ASM-C NDC table. Should Indacteral be included in the measure?

No. Indacteral was removed from the ASM-C NDC list and noted in a Word document posted with the NDC lists on November 2, 2012. The medication was reviewed by the HEDIS Expert Pharmacy Panel and determined to be not indicated for asthma, so it was removed from the measure. The MY 2013 P4P manual will reflect this change.

This applies to the following Programs and Years:

4.15.2013 Scoring for CR 2, Element C: Agreement and Collaboration with Health Plans How is CR 2, Element C scored for organizations that may not have a delegation agreement in place?

Element C is scored "NA" for organizations that do not have a delegation agreement, and there is no reporting to the client.

This applies to the following Programs and Years: