FAQ Directory

Yes. To receive credit for factor 9, the work plan must address all ten items listed Work Plan in the explanation.

No. Organizations must assess members cultural, racial, ethnic and linguistic needs then take actions based on its findings. Leaving out one or more of the required assessment areas would not meet the intent of the element.

No. While the organization may have different complaints and appeal category for business purposes, it must analyze and report both complaint and appeal data by the five specified categories for NCQA purposes. Even if the organization has no complaints or appeals in one or more reporting categories, it must still demonstrate its analysis and report the number of complaints and appeals for all five categories.

No. Data collection methodology must be sound enough to produce valid and reliable results but achievement of significant improvement is not required for QI 10 Element A.

No. More than one practitioner must be involved in QI program activities. Participating practitioners must represent a broad spectrum of specialties, as appropriate.

Yes. If performance issues are identified through organization-wide analysis, the organization must perform an analysis at the practitioner level to identify the cause. Practitioner-level assessment may include the total population or a statistically valid sample.

For MY 2011 P4P tables CWP-C and URI-D, crosswalk to the HEDIS 2012 NDC list for table CWP-C.

*Note: The MY 2011 P4P crosswalk to HEDIS 2012 NDC List posted on December 8, 2011, has been corrected.

For MY 2011, POs should use their own designation of PCPs. This is in alignment with how P4P had defined PCPs for the IT-Enabled Systemness Domain.

No. For the MUHIT domain, functionality means a fully operational and implemented system that has been in use since October 1, 2011. An organization that has an EHR in place, but is not using it as defined in the measure intent statement, does not receive any points for that measure.

In MY 2011, health plans may submit results for the Medicare product line and for the commercial product line. Because the Medicare product line is now reported by health plans, the Health Plan Clinical and Testing Measure file layouts have three tabs for the possible reporting scenarios (commercial HMO/POS and Medicare, commercial HMO/POS only, Medicare only).

Scenario 1: The health plan has both commercial HMO/POS and Medicare product lines

Clinical Measure File Layout: Plans that report for both the commercial HMO/POS and Medicare populations must have 66 clinical measure IDs per DMHC ID/Sub Unit, even if an individual PO has only commercial or Medicare enrollment.

Testing Measure File Layout: Plans that report for both the commercial HMO/POS and Medicare populations must have 31 clinical measure IDs per DMHC ID/Sub Unit, even if an individual PO has only commercial or Medicare enrollment.

Refer to Tab (5) Sample HP FileBoth Commercial and Medicare

Examples 1_3: The plan has commercial and Medicare product lines; Pos 11111-00, 22222-03, 22222-05 and 33333-05 also have commercial and Medicare members: the plan submits commercial and Medicare data for these Pos.

Example 4: The plan has commercial and Medicare product lines; PO 44444-01 has only Medicare members: the plan submits Medicare data for PO 44444-01 and populates commercial rows for PO 44444-01 with zero enrollment, zero denominator, zero numerator and rate NB.

Scenario 2: The health plan has commercial HMO/POS product line only

Refer to Tab (6) Sample HP FileCommercial Only: Plans that have the commercial product line only submit data for the commercial product. There are no rows for the Medicare product.

Clinical Measure File Layout: The plan reports 59 clinical measure IDs per DMHC ID/Sub Unit for the commercial product.

Testing Measure File Layout: The plan reports 10 testing measure IDs per DMHC ID/Sub Unit for the commercial product.

Scenario 3: The health plan has Medicare product line only

Refer to Tab (7) Sample HP FileMedicare Only: Plans that have the Medicare product line only submit data for the Medicare product. There are no rows for the commercial HMO/POS product.

Clinical Measure File Layout: The plan reports 7 clinical measure IDs per DMHC ID/Sub Unit for the Medicare product.

Testing Measure File Layout: The plan reports 21 clinical measure IDs per DMHC ID/Sub Unit for the Medicare product.

For the MUHIT domain, intent refers to the measures criteria, as specified in the Intent section. For Required Submission item 4, count the number of PCPs, or the number of patients assigned to PCPs who meet the criteria listed for each measure. Assign the number of points that correspond to the percentage of PCPs meeting the measures intent.

The answer depends on whether the organization presents sanction information every 30 days to its Credentialing Committee. If so, there is no need to report it at the time of recredentialing. If not, the organization would need to verify and present adverse information to the Credentialing Committee at recredentialing.