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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2.16.2013 Care for Older Adults For the functional status assessment indicator, the fourth bullet requires notation of at least three of the four components: cognitive status, ambulation status, sensory ability and other functional independence. For "sensory ability," must all three components (hearing, vision, speech) be documented to meet the criterion?

Yes. All three components must be evaluated to fulfill the sensory ability component.

This applies to the following Programs and Years:
HEDIS 2013

2.16.2013 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents If height and weight are documented in the medical record during the measurement year, may the organization calculate BMI percentile at a later date?

Yes. The BMI percentile may be calculated by the organization at a later date. It must be calculated and documented in the medical record during the measurement year to be eligible for use in HEDIS reporting.

This applies to the following Programs and Years:
HEDIS 2013

2.16.2013 Adult BMI Assessment May a member's weight and BMI be noted on different dates of service in the medical record?

Yes. Weight and BMI may be noted on different dates of service as long as they are documented in the medical record during the measurement year or year prior to the measurement year.

This applies to the following Programs and Years:
HEDIS 2013

2.16.2013 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents May a member's height, weight and BMI percentile be noted on different dates of service in the medical record for the BMI Percentile indicator?

Yes. Height, weight and BMI percentile may be noted on different dates of service as long as they are documented in the medical record during the measurement year.

This applies to the following Programs and Years:
HEDIS 2013

2.15.2013 NA option for Medicare product line in Element B For QI 9 Element B, which requires organizations to adopt and distribute preventive health guidelines for perinatal care, care for children up to 24 months, care for children 2-19 years old, care for adults 2-64 years old and care for adults 65 years and older, is there an NA option for Medicare product lines that only serve individuals who are 65 years and older?

Yes. QI 9, Element B is NA for perinatal care, care for children up to 24 months, care for children 2-19 years old and care for adults 2-64 years of age for Medicare product lines that only serve individuals who are 65 years and older.

This applies to the following Programs and Years:

2.15.2013 Eligibility for accreditation prior to establishing relationships Is an organization eligible for accreditation if it does not perform the functions specified within the standards and guidelines directly and has not entered into an effective service agreement with another entity to perform the function?

No. To be eligible the organization must perform the functions addressed in the Standards and Guidelines (e.g., QI, UM, CR, RR, and MEM, if applicable), either directly or through a service agreement. If the organization uses a service agreement, the agreement must specify functions covered and be effective before eligibility can be determined.

All other listed eligibility criteria also must be met.

This applies to the following Programs and Years:

1.16.2013 Medical Record Review Validation Can the plan choose to rotate a measure that failed MRR validation?

The intent of measure rotation is to reduce chart review, not be a means to select the best rate possible. However, NCQA does not specifically prohibit this approach. Please note, if the reason for failing can be seen as possibly affecting other measures in the group, the auditor may elect to review those other measures.

This applies to the following Programs and Years:
HEDIS 2013

1.16.2013 Medical Record Review Validation Can auditors provide plans with the measures selected for over-read earlier than May 1? What if the plan finishes MRR earlier?

The current timeline says that the auditor selects the measures for review on May 1 and not before; however, if the auditor reviews the health plans internal timelines, and finds that the plan expects to finish MRR early, it is acceptable that the auditor send the measure list when all chart review is complete and he has received a final count of numerator hits for each hybrid measure. For example, if the plan finishes all chart chases on April 29 and provides the numerator count lists, the auditor can select the measures for validation and start the process early.

Note: If the auditor allows for an earlier MRRV timeline, the plan may have to adjust other deadlines affected by this change.

This applies to the following Programs and Years:
HEDIS 2013

1.16.2013 Asthma Medication Ratio (AMR) In Table AMR-D, ICD-9-CM Diagnosis code 506.4 is listed under both the emphysema and COPD rows. Is this correct?

No. Remove code 506.4 from the emphysema row. This will be corrected in the MY 2013 manual.

This applies to the following Programs and Years:

1.16.2013 General Guidelines Is there a deadline for updating administrative rates with new sources of supplemental data?

Yes, the December Update included a modification to the audit timeline that requires all supplemental database activities be concluded by 5/1 in the reporting year. NCQA requires this deadline to allow sufficient time for audit review and possible corrections. The update should be made in the HEDIS Audit Timeline in Volume 5, on page 52 and in Volume 2, on page 17. This sentence should be added: "Auditor finalizes approval of Supplemental Databases, policies, procedures, and content (data)." by May 1.

This applies to the following Programs and Years:
HEDIS 2013

1.16.2013 Medical Record Review Validation For measures that are heavily or entirely reliant on MRR data (e.g., COA, ABA, WCC, CDC BPs), if an organization attempts MRR validation and fails, or is able to retrieve a only small percentage of charts, can they report an administrative rate as low as 0% (assuming no other issues are identified)?

A low administrative rate, even 0%, can be reported, if the plan wants to submit such a rate and the auditor finds no bias or other problems in the administrative process.

This applies to the following Programs and Years:
HEDIS 2013

1.16.2013 General Guidelines Should Medicare Advantage (MA) members who elect the hospice benefit and choose to remain enrolled in the MA plan be excluded from MA HEDIS denominators?

No, not for HEDIS 2013 reporting; however, beginning with HEDIS 2014, exclude MA members who elect the hospice benefit available through original Medicare. This change will be in the HEDIS 2014 Volume 2 specifications.

This applies to the following Programs and Years:
HEDIS 2013