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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7.18.2018 CM 04 (Pediatric Specific) Where can I find an example of a patient care plan for a pediatric patient- centered medical home?

Care coordination resources, including a sample patient care plan can be found at: 
https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/Pages/Care-Coordination.aspx 

National Center for Medical Home Implementation Building Your Medical Home Guide: 
https://medicalhomes.aap.org/Pages/Managing-Your-Patient-Population.aspx
https://medicalhomes.aap.org/Documents/PediatricCarePlan.pdf 

NICHQ Care Plan Template: https://www.nichq.org/resource/nichqs-care-plan-template 
 

PCMH 2017

7.18.2018 CC 10 (Pediatric Specific) AAP resource:

7.18.2018 AC 07 (Pediatric Specific) How do practices account for adolescent confidentiality issues; for example, if an adolescent asks that information not be shared with a parent?

Pediatric practices are not penalized for not sharing information with parents if the adolescent requests that information not be shared, but applicants must explain the exclusion of adolescent patients in the associated documentation. The system must include only legitimate requests for information based on state and federal confidentiality requirements
 

AAP resources:  

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PCMH 2017

7.16.2018 Use of Opioids at High Dosage Why is buprenorphine included in the Use of Opioids From Multiple Providers (UOP) and Risk of Continued Opioid Use (COU) measures, but not in the Use of Opioids at High Dosage (UOD) measure?

Unlike UOP and COU, UOD requires the conversion of all dispensed opioids into morphine milligram equivalents (MME). The most current MME conversion file, published by the Centers for Disease Control and Prevention, removes buprenorphine, a partial opioid agonist, and states that the drug is not likely to be associated with overdose in the same dose-dependent manner as pure opioid agonists. NCQA removed it from the UOD measure in HEDIS 2019. This change aligns with the decision made by the Pharmacy Quality Alliance, the organization that developed the measure from which UOD was adapted for use in HEDIS.

HEDIS 2019

7.16.2018 General Guidelines Does a member enrolled in palliative care meet criteria for the hospice exclusion outlined in General Guideline 17?

Palliative care is not the same as hospice care because it can begin when a patient is diagnosed or is undergoing treatment and may not indicate being near end of life. The hospice exclusion requires evidence that the member is receiving hospices services. Documentation that a member is in palliative care is not part of the exclusion.

HEDIS 2019

7.15.2018 Medical necessity review for personal care services Does NCQA require medical necessity review for personal care services, such as cooking, cleaning and transportation?

No. Medical necessity review is not required for personal care services and other activities of daily living in UM 4–UM 7. However, if these services are covered benefits, any denial decision may be appealed and is included in the scope of appeal file review for UM 9.

HP 2018

7.09.2018 KM 08 (Pediatric Specific) Are there health literacy training programs tailored to pediatric practices?

No, but health literacy training programs are only a suggested approach for addressing communication needs and reducing barriers for patients and their families to access and understand health and safety information.

  • AAP resources: 
           – AAP Pedialink course on health literacy: https://shop.aap.org/health-literacy/  
  • Other resources:
HRSA: Culture, Language, and Health Literacy Tools & Resources: https://www.hrsa.gov/about/organization/bureaus/ohe/health-literacy/resources/index.html  

 

 

PCMH 2017

6.14.2018 KM 03 (Pediatric Specific) What type of standardized screening tool for depression would meet the requirement for a pediatric population?

NCQA is not prescriptive regarding which depression screening tool is used as long as it’s a standardized tool. Some depression screening tool examples that would be appropriate for adolescents include but are not limited to PHQ2, PHQ9, PHQ-A, PSC, PSC-Y, RAAPS, or HEADSS. 

PCMH 2017

6.14.2018 TC 03 (Pediatric Specific) What are some examples of PCMH-oriented collaborative activities for pediatric practices?

Pediatric practices may want to look into quality improvement projects offered by state AAP chapters and national AAP. The AAP QI Webpage lists a variety of opportunities: https://www.aap.org/en-us/professional-resources/quality-improvement/Pages/ActivityList.aspx

PCMH 2017

6.14.2018 KM 12B (Pediatric Specific) Does a list of pediatric patients from two age groups (e.g., 2-year-olds and 6-year-olds) that are “behind” on immunizations meet the requirements of this criterion?

No. Practices may not use the same immunization for two age groups, and must identify two different immunizations for this criterion.

PCMH 2017

6.14.2018 KM 02E (Pediatric Specific) Would unhealthy behaviors associated with a parent’s behavior be acceptable for KM 02 E since they are responsible for preventing these behaviors?

Yes, unhealthy behaviors can be the result of parent behavior but ultimately, we're looking for the unhealthy behaviors demonstrated by the patient (child). Secondhand smoke may be a direct example of a parent’s behavior affecting the child’s health and poor oral hygiene may be a child’s unhealthy behavior, but could result from lack of parental oversight or health literacy.

PCMH 2017

6.14.2018 KM 02F (Pediatric Specific) How do clinicians assess the pediatric patient's ability to interact with other kids in a normal fashion? If the child is functioning normally in school would that suffice?

A social-emotional screening tool would be the best route to assess this, and the recommendation is for that screening to be done on a regular basis.

PCMH 2017