FAQ Directory

No. There are no Medicare member exclusions. Remove the second bullet from Exclusion 1, which reads:

• Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
  • Enrolled in an Institutional SNP (I-SNP) any time during the measurement period.
  • Living long-term in an institution any time during the measurement period, as identified by the LTI flag in the Monthly Membership Detail Data File. Use the run date of the file to determine if a member had an LTI flag during the measurement period.

This applies to the following Programs and Years:

As noted in the Glossary appendix, NCQA’s long-standing definition of “annual” is 12 months plus a 2-month grace period (12–14 months). “Grace period” refers to allowing organizations to complete an activity after it is due and not before it is due.

This applies to the following Programs and Years:

Plans can have multiple ratings for one product within the same state because they might have certain state or contractual submission requirements that fall outside of the combined submission requisite that they send to NCQA for Accreditation purposes. Therefore, this results in plans submitting one combined submission (required) for Accreditation and then they still elect to select other submissions for state or other contractual obligations, which NCQA includes as part of its Ratings program.

This applies to the following Programs and Years:

Yes. The 12-17 years age stratification is reported for the Follow-Up on Positive Screen numerator and should be added to the age stratification on page 240 of MY 2023 HEDIS for QRS Version.

This applies to the following Programs and Years:

For measures with hybrid reporting methodology (HBD, BPD, EED), members who have not had a diagnosis of diabetes but receive diabetes medications for conditions other than diabetes (e.g., weight loss, heart failure) may be identified as valid data errors and replaced with a member from the oversample.
To meet criteria for a valid data error for these measures, the medical record must contain no evidence of diabetes and must contain evidence to substantiate the data error (how the member wound up in the measure, why it is incorrect). It is expected that the medical record will not contain evidence of diabetes, and will contain documentation that the patient is on the medication, and why. This documentation, in combination with no other documentation of diabetes in the medical record, meets criteria for a valid data error. Valid data errors are subject to review by the auditor.
Valid data errors work for the Hybrid Method only because medical record data are used to ensure that the member does not have diabetes. For the administrative method, these members remain in the measure as medical records are considered supplemental data that may not be used for identifying valid data errors, or when reporting the HBD, BPD and EED measures using the administrative method, or the KED, SMD, EDH and SPD measures, which are administrative-only measures.
We are working to refine the diabetes denominator related to off-label medication use. The next annual HEDIS public comment period is planned for February–March 2023, but organizations may submit comments on any measure, at any time, through PCS (you do not need to wait until February).

*This FAQ applies to the following measures: Hemoglobin A1c Control for Patients With Diabetes (HBD), Blood Pressure Control for Patients With Diabetes (BPD), Eye Exam for Patients With Diabetes (EED), Kidney Health Evaluation for Patients With Diabetes (KED), Statin Therapy for Patients With Diabetes (SPD), Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD), and Emergency Department Visits for Hypoglycemia in Older Adults With Diabetes (EDH)

This applies to the following Programs and Years:

Yes. The following changes apply to the 2022 MA Deeming Module:

• MA 19, Element A:
  • Clarified that the organization’s delegation agreements for MA standards must include a statement requiring delegates to adhere to MA regulations.
• SNP 2, Element A:
  • Revised factor 3 to reference both initial and annual health risk assessments (HRAs).
  • Clarified in the explanation that the organization must conduct an initial and annual HRA using a comprehensive HRA tool and ensure that results are addressed in the member’s individualized care plan, as required under 422.101(f)(1)(ii).
• SNP 2, Element C:
  • Added factor 2: “The organization annually, and within the first 12 months of enrollment, conducts face-to-face encounters between the member and their care team.” The face-for-face encounter must be either in person or through visual, real-time, interactive telehealth.
  • Adjusted the scoring to reflect the new factor.
  • Revised the explanation to include “Factor 2: Face-to-face encounter” subhead and text. The encounter must be between the member and representative from any of the following:
    • The ICT.
    • The organization’s case management and coordination staff.
    • A health care provider contracted with the health plan.
• SNP 3, Element A:
  • Revised factor 5 to read: “Including the ICT, as outlined in SNP 2, Element C, to oversee the MOC’s evaluation and monitoring process.”
  • Revised the scope of review to clarify that the organization includes the ICT in the monitoring and evaluation process.
  • Replaced the “Factor 5: Appropriate personnel” subhead with “Factor 5: The ICT” and revised the explanation to read:
    • The organizational chart documents the organization’s reporting structure and staff responsible for administering the MOC program, including the ICT, as specified in SNP 2, Element C, factor 1. According to the defined MOC, the organization must use an ICT to manage member care. The ICT includes:
      • Practitioners with demonstrated expertise and training,
      • Training in a defined role appropriate to their licensure in treating individuals similar to the targeted population of the organization, as applicable.

This applies to the following Programs and Years:

No. The use of another entity’s evidence-based content within the organization’s case management system is not considered delegation if the organization maintains control over how the content is used and can customize it as needed. The evidence used to support the content must be cited.

This applies to the following Programs and Years:

No. The use of another entity’s evidence-based content within the organization’s case management system is not considered delegation if the organization maintains control over how the content is used and can customize it as needed. The evidence used to support the content must be cited.

This applies to the following Programs and Years:

No. The use of another entity’s evidence-based content within the organization’s case management system is not considered delegation if the organization maintains control over how the content is used and can customize it as needed. The evidence used to support the content must be cited.

This applies to the following Programs and Years:

No. The use of another entity’s software to collect credentialing information is not considered delegation unless the other entity also reviews the information on the organization's behalf. NCQA standards allow organizations to use software to collect credentialing information from approved sources, as long as organization staff document that the information was reviewed and verified.

This applies to the following Programs and Years:

This applies to the following Programs and Years:

This applies to the following Programs and Years: