FAQ Directory

This applies to the following Programs and Years:

We anticipate that PCV20 will be added to the CIS value sets in the HEDIS MY 2024 Technical Update, scheduled for release on April 1, 2024.
Although the PCV20 vaccine is not included in the measure for MY 2023, NCQA does not anticipate this will impact performance. The measure denominator only includes children who were at least 18 months old and expected to have already completed the pneumococcal series by June 2023 (the month when ACIP recommended PCV20).
 

This applies to the following Programs and Years:

If an organization delegates more than 50% of primary source verifications and one or more of its delegates loses Accreditation/Certification status, NCQA considers this a Reportable Event. The organization must notify NCQA (through My.NCQA.org) within 30 calendar days.

This applies to the following Programs and Years:

Typically, no as health plan staff are not practicing practitioners within the health plan's network. The intent of collaboration requirements are for organizations to demonstrate collaboration between their behavioral healthcare delivery system (network practitioners) and medical care delivery system (network practitioners). 

Note: Demonstrating collaboration with an MBHO is acceptable for the collaboration with “behavioral healthcare practitioners” component of the requirement.

This applies to the following Programs and Years:

This means that the information is not all medical jargon. So instead of the care plan stating, “1 PO BID”, the practice may say “take one by mouth two times a day.” Instead of hardcoded complex diagnosis names and codes, write the diagnosis in common language. For example, instead of only providing the diagnosis of “dyspnea,” use “shortness of breath.”  

The intent is to ensure that the patient understands his/her condition(s), goals, and plans to follow to improve their health.  

This applies to the following Programs and Years:

The document should not simply be a hardcoded paper that auto-populates structured fields from the EHR into the document. It should contain language showing that the patient provided input and understands the plan. NCQA is not prescriptive on specific verbiage that must be in the care plan. 

The intent of CM 04 is to give the patient ownership and the power to improve their health outcomes. Engaging the patient in the development of their care plan can result in greater success and adherence to treatment goals.  

This applies to the following Programs and Years:

“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.   

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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. 

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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).

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years: