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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1.09.2023 PCSP January 2023 Summary of Updates What changes were made to the PCSP Standards and Guidelines for Version 5.1?

TopicUpdate Highlights
Front MatterAdded definitions of “electronic health record (EHR)” and “certified electronic health record technology (CEHRT).”
TC 05Added a note that beginning in 2024, practices will be required to have an EHR.
KM 09Added a note that gender identify and sexual orientation requirements apply to all patients 18 years of age and older.
CM 10Replaced “person-driven outcomes approach” with “person-centered outcomes approach.”

PCSP 2019

12.27.2022 Annual Reporting Why are evaluators asking for the practice to provide an explanation for performance rates? What should the explanation consist of?

Evaluators may ask practices to provide an explanation, or context and reasoning, for the data submitted. If a reported performance rate seems too low (or too high), the evaluator may ask the practice to enter an explanation of the performance in the Notes section of QPASS.  

Practices are expected to provide a clear and succinct response as to why their performance rate is low, or unusually high. Because practices are expected to have fully implemented PMCH workflows and processes, the Review Oversight Committee (ROC) members would like to understand the reasoning behind the reported performance rates.  

PCMH 2017

12.15.2022 Auditing Data Collected Using Natural Language Processing (NLP) Is a Continuity of Care Document (CCD) acceptable for primary source verification when auditing data collected by NLP?

No. Data collected using NLP needs to be audited back to the legal health record. CCDs are not considered the legal health record or proof of service, and are not a replacement for an electronic health record.  

HEDIS 2022

12.15.2022 Advance Care Planning (ACP) When using supplemental data, does an advance care plan executed before the measurement year meet criteria?

No. The measure requires evidence of an advance care plan during the measurement year, dated during the measurement year. If the advance care plan is scanned into the EMR and dated in the measurement year, it meets criteria. If the plan is found in the EMR or member record from a prior year, it does not meet criteria unless there is dated evidence that it was reviewed or discussed during the measurement year.

HEDIS 2022

12.15.2022 Transitions of Care (TRC) When using the fifth bullet to meet criteria for Medication Reconciliation Post-Discharge, if documentation indicates that the medication reconciliation was performed during a post-op/surgery follow-up visit by the surgeon who performed the surgery or the provider who admitted the member, or if the surgery is for a procedure that is typically performed inpatient, does this count as evidence that the provider was aware of the hospitalization at the time of the visit?

No. Medication reconciliations performed during a post-op/surgery follow-up visit alone do not meet criteria even if the visit was performed by the provider who admitted the member or who performed the surgery, or if the procedure is typically performed inpatient. The intent is that medical record documentation must support awareness of the hospitalization (denominator event) at the time of the medication reconciliation, even if the provider admitted the member or saw the member during the hospitalization, or if the procedure is typically performed inpatient. 

HEDIS 2022

12.15.2022 Sampling Guidelines—Multiple Measures using a common sample If members are deceased are they removed from all measures that use the same sample?

Yes. If multiple measures use the same sample, a deceased member is removed from all related samples. For example, deceased members who are removed from the Childhood Immunization (CIS) sample would also be removed from the Lead Screening (LSC) sample. Similarly, deceased members who are removed from the Hemoglobin A1c Control for Patients With Diabetes (HBD) sample would also be removed from Blood Pressure Control for Patients With Diabetes (BPD) and Eye Exam for Patients With Diabetes (EED) samples. This FAQ was previously posted in November 2022 and was updated to remove the reference to the KED measure.

HEDIS 2022

12.15.2022 General Guideline 28 and International Normalized Ratio Monitoring for Individuals on Warfarin (INR) Should organizations use laboratory claims and data for the INR Test Value Set in the International Normalized Ratio Monitoring for Individuals on Warfarin Pharmacy Quality Alliance measure?

Yes. Although LOINC codes were removed from the INR Test Value Set, organizations should use laboratory claims and data for this value set, in addition to medical claims. This value set should be listed in General Guideline 28 with other value sets that do not contain LOINC codes.

Exchange 2023

11.16.2022 General Guideline 28: Identifying Events/Diagnoses Using Laboratory or Pharmacy Data Should organizations use laboratory claims and data for the Drug Test Value Set in the Annual Monitoring for Persons on Long-Term Opioid Therapy Pharmacy Quality Alliance measure?

Yes. Although LOINC codes were removed from the Drug Test Value Set, organizations should use laboratory claims and data for this value set. This value set should be listed in General Guideline 28 with the other value sets that do not contain LOINC codes but should use laboratory claims and data.

**This FAQ applies to QRS MY 2022.

Exchange 2022

11.15.2022 Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) and Unhealthy Alcohol Use Screening and Follow-Up (ASF-E) In the data elements reporting tables for Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) and Unhealthy Alcohol Use Screening and Follow-Up (ASF-E), the reporting instructions for the initial population and exclusions data elements state, “For each Metric and Stratification.” However, these measures have the same initial population and exclusions reported for each metric. Should the reporting instructions state “For each stratification, repeat per metric”?

Yes. The reporting instructions for the initial population and exclusions data elements for ASF-E and DSF-E for MY 2022 and MY 2023 are incorrect. The reporting instructions should state, “For each stratification, repeat per metric” for the initial population and exclusions data elements. Refer to the PDF  for the corrected data elements tables.
Note: The information is correct in IDSS (the validations check "For each stratification, repeat per metric” for the initial population and exclusions data elements).

 

**This FAQ applies to both HEDIS Volume 2 MY 2022 and HEDIS Volume 2 MY 2023

HEDIS 2022

11.15.2022 Lead Screening in Children (LSC) In the MY 2022 specifications for Lead Screening in Children (LSC), there are data elements for ExclusionAdminOptional and ExclusionMedRecsOptional. This measure does not have optional exclusions. Are these data elements in error?

Yes. The data elements for “ExclusionAdminOptional” and “ExclusionMedRecsOptional” are not reported for MY 2022. These data elements and reporting instructions should be removed from Table LSC-1: Data Elements for Lead Screening in Children.

HEDIS 2022

10.15.2022 Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?

Yes. Using UM 13: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 13, Element A: Delegation Agreement

  • Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution (e.g., UM 11, Element B (annual updates for pharmaceutical restrictions/preferences).
    • Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance, if applicable.
    • Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
  • Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.

UM 13, Element C: Review of the UM Program

  • Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates.
  • Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
    • Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).

Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit. This must be specified in the delegation agreement.
 

HP 2023

10.15.2022 MBHO: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?

Yes. Using UM 12: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 12, Element A: Delegation Agreement

  • Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution
    • Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance.
    • Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
  • Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.

UM 12, Element C: Review of the UM Program

  • Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates
  • Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
    • Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).

Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit. This must be specified in the delegation agreement.

MBHO 2022