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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2.15.2012 Personal care add-on benefits Are personal care services that are add_on benefits, such as cooking, grooming, transporting, cleaning and assistance with other ADL activities that are not part of medical benefit, subject to review under UM 4-UM 7?

No. Add-on personal care services do not fall within the scope of UM 4-UM 7, but they can be appealed under RR 2 or UM 8 and UM 9. Personal care services that are a part of the medical benefit fall within the scope of medical necessity review if an assessment must be done to determine the member is eligible for the services or if the services will be covered. In such cases, the services would be within the scope of UM 4-UM 7.

2.15.2012 Notification of expedited external review for Medicare in UM 7, Element D How is factor 4 scored for Medicare members in UM 7, Element D?

Factor 4 is scored "NA" if a plan issues a Notice of Denial of Medical Coverage (NDMC) for non-inpatient medical services denials for Medicare members.

2.15.2012 Facility DEA What type of documentation should health plans include in credentialing files, if the DEA allows all practitioners in a community hospital/clinic to be covered under facility DEA?

An organization must provide documentation that the community hospital/clinic meets DEA requirements. The organization must also include evidence of verification of the facility DEA in the credentialing file.

2.15.2012 Behavioral healthcare practitioner involvement in program design Must the behavioral healthcare practitioner involved in program design be employed by the organization, or may the behavioral healthcare practitioner be a consultant?

It is not necessary for a behavioral healthcare practitioner to be an organization employee. Organizations may use an external consultant.

2.14.2012 Notification of expedited external review for Medicare in UM 7, Element G How is factor 4 scored for Medicare members in UM 7, Element G?

Factor 4 is scored "NA" if a plan issues a Notice of Denial of Medical Coverage (NDMC) for non-inpatient medical services denials for Medicare members.

1.17.2012 Use of Virtual Hold in call abandonment rates Our member phone system measures wait time. If the wait time hits a certain threshold, members can hang up, keep their place in the queue and receive an automatic call back when the next customer support person is available. The system is set to call back every five minutes, for three attempts. When members answer the call-back, they are connected to the customer support person. If a member does not answer after three attempts, is the call considered abandoned, based on the Call Abandonment criteria?

Yes. If the member does not answer the call-back, it is counted as abandoned. If the member answers the call-back and the reports show the results, the call is not counted as abandoned because the member was kept in the queue.

For timeliness (Element C, factor 1), because it is unlikely that the system would start the call-back process before 30 seconds, the call counts as answered outside the 30 seconds.

1.17.2012 Use of Virtual Hold in call abandonment rates Our member phone system measures wait time. If the wait time hits a certain threshold, members can hang up, keep their place in the queue and receive an automatic call back when the next customer support person is available. The system is set to call back every five minutes, for three attempts. When members answer the call-back, they are connected to the customer support person. If a member does not answer after three attempts, is the call considered abandoned, based on the Call Abandonment criteria?

For timeliness (Element C, factor 1), because it is unlikely that the system would start the call-back process before 30 seconds, the call counts as answered outside the 30 seconds.

1.17.2012 Use of Virtual Hold in call abandonment rates Our member phone system measures wait time. If the wait time hits a certain threshold, members can hang up, keep their place in the queue and receive an automatic call back when the next customer support person is available. The system is set to call back every five minutes, for three attempts. When members answer the call-back, they are connected to the customer support person. If a member does not answer after three attempts, is the call considered abandoned, based on the Call Abandonment criteria?

For timeliness (Element C, factor 1), because it is unlikely that the system would start the call-back process before 30 seconds, the call counts as answered outside the 30 seconds.

1.16.2012 Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women A new exclusion code (ICD 279) was added to the Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women measure, but no guidance was provided on time frame to allow the exclusion.

For this exclusion, look back as far as possible in the members history.

1.16.2012 PR 1: Internet Portal for Notification of Patient Engagement May organizations notify practitioners via an Internet portal for PR 1, Element A, factor 8?

Yes, if the organization's documented process includes how it notifies practitioners that the information is available on the Internet; and if the organization informs practitioners where the information is located. If all practitioners do not have access to the portal, the organizations process must include how it notifies these practitioners of patient engagement.

1.16.2012 Proportion of Days Covered by Medications How should organizations count days when a member is covered by a drug in step 2 of the numerator for each rate? The specification states that if prescriptions for the same drug overlap, the prescription start date should be adjusted to be the day after the previous fill has ended. Does this mean that if a member fills a prescription for a 30-day supply of a drug on January 1, 2011, and fills another prescription for the same drug on January 15, 2011, also with a 30-day supply, the days covered is 45 days (30 days for the prescription filled on January 1; 15 days for the drug filled on January 15)?

Sixty days are covered. The first prescription lasts 30 days, starting January 1. If you move the next prescription's start date to the day after the previous fill has ended, it becomes January 31. The end date is March 1. In essence, the start date and the end date of the second prescription both move.

1.16.2012 Proportion of Days Covered by Medications How do you account for claim reversals?

PDC measures are calculated through use of paid, nonreversed claims for target medications. If the drug claims dataset contains claim reversals (and paid claims that were reversed), analysts must ensure that the reversed claims are not used to calculate PDC. Claim reversals can be identified through multiple methods because there may be multiple fields in a drug claim that indicate whether it is a reversal. Many drug claims datasets have a Count field that contains a 1 for a paid claim and a -1 for a claim reversal. The dataset may also have a field called Reversal that contains a Y if the claim is a reversal claim, or an N if it is not a reversal. Reversal claims typically have a negative quantity and a negative cost.

The claim reversal (-1 in the Count field or Y in the Reversal field) may have a Claim Number that is identical to the original claim being reversed. If the Claim Number for the reversal claim is not identical to the Claim Number for the original claim, analysts can create coding logic that will identify the reversed claim as immediately preceding the claim reversal. This latter approach is not usually necessary because most drug claims datasets allow a claim reversal to be linked to an original claim.