Yes. AR-KM 1 confirms that practices meet PCMH KM 15, in which more than 80% compliance is required for medication lists. A rate less than or equal to 80% does not meet criteria.
PCMH 2017
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6.13.2022 For AR-KM 1: Medication Lists (aligns with PCMH KM 15), is a reported rate <80% automatically marked as “Not Met”? For AR-KM 1: Medication Lists (aligns with PCMH KM 15), is a reported rate <80% automatically marked as “Not Met”? (PCMH AR 2022)
6.13.2022 AR CC 4 For AR CC 4: Referral Tracking (aligns with PCMH CC 11), must practices meet a percentage threshold to meet criteria? (PCMH AR 2022)
No. There is no percentage threshold for referral tracking measures. The expectation is that practices track important referrals routinely; if performance is lower than expected, the practice should enter the rationale for their low percentage in the Notes from the Organization section in QPASS.
For example, if data show a 30% return rate, that means 70% of the practice’s referred patients never had a report returned to their PCP.
PCMH 2017
6.13.2022 Is there a minimum threshold requirement when reporting a rate for Annual Reporting (PCSP AR 2022)?
It depends. If the AR requirement aligns with a PCSP criteria that explicitly specifies a threshold, then that value would be the minimum threshold. However, if a threshold is not explicitly stated in the criteria, then 80% or more is expected to ensure consistent application of the process. Please note that there may be some cases where it’s acceptable for the rate to fall below 80%.
An explanation in the Note section of Q-PASS is required for practices that report a rate less than 80% for the following criteria: AR-AC 01 [Timely Clinical Advice by Telephone], AR-CC 04 [Tracking Lab Test Results], and AR-CC 05 [Tracking Imaging Test Results].
PCSP 2019
6.13.2022 AR CC 04 For AR-CC 4: Diagnostic Test Tracking (aligns with PCSP Transform CC 5), must practices meet a percentage threshold to meet criteria? (PCSP AR 2022)
No. There is no percentage threshold for diagnostic test tracking measures. The expectation is that practices track all diagnostic tests routinely; if performance is lower than expected, the practice should enter the rationale for their low percentage in the Notes from the Organization section in QPASS.
For example, if data show a 30% return rate, that means 70% of the practice’s ordered tests never had a report returned to their PCP.
PCSP 2019
6.13.2022 AR KM 01 For AR-KM 01: Medication Management (aligns with PCSP Transform KM 9), is a reported rate <80% automatically marked as “Not Met”? (PCSP AR 2022)
6.13.2022 Why do I need to provide more information for a low denominator or rate if there is no minimum requirement?
It is to ensure patient safety and routine implementation of medical home activities. Depending on the population served and/or the reporting period, a small denominator is unexpected and may indicate issues (e.g., with data, documentation, implementation). Providing additional information allows the practice to explain—beyond the numbers—when performance is outside the expected range.
PCSP 2019
5.24.2022 Updated: Boilerplate Language in Delegation Agreements for System Controls May organizations’ delegation agreements contain boilerplate language for system controls delegates?
Yes, if the language specifies that the delegate must meet NCQA requirements (UM 12, Elements A and C, factor 6; UM 13, Element C, factor 5; CR 1, Element C, factor 4; CR 8, Element C, factor 5), template language may be used in the delegation agreement. Language specific to each delegate is not required.
Note: The underlined text is a correction. The previous FAQ referred to the wrong element.
HP 2022
5.16.2022 MY 2022 Technical Update – COL-E Measure In the updated version of the COL-E measure that was re-released in the MY 2022 Technical Update, the “Total” data element listed in the age column is not highlighted in Table COL-E-A-3: Data Elements for Colorectal Cancer Screening. Should this cell be highlighted?
5.16.2022 Reducing the Sample for CIS for MY 2022 Reporting May organizations reduce the minimum required sample size for the Childhood Immunization Status measure when reporting MY 2022?
5.15.2022 Clarify scope for UM 12, Elements A and C What are the differences in scope for system controls at the factor level in UM 12, Elements A and C?
For UM 12, Elements A and C:
- Factors 1–5 apply to receipt and notification dates, covered in UM 5 and UM 8–UM 9.
- Factor 6 applies to all UM system data for managing denials and appeals (not only the dates specified in factors 1–5), covered in UM 4–UM 7 and UM 8–UM 9.
- Factor 7 requires a monitoring process that covers compliance with all policies and procedures described in factors 1–6.
HP 2022
5.15.2022 Clarify scope for CR 1, Element C What are the differences in scope for system controls at the factor level in CR 1, Element C?
For CR 1, Element C:
- Factor 1 applies to verification source information from credentialing and recredentialing cycles, covered in CR 3, Elements A–C.
- Factor 2 applies to modified credentialing verification information from initial credentialing and recredentialing cycles, covered in CR 3, elements A–C.
- Factors 3–4 apply to all information associated with credentialing/recredentialing of practitioners, covered in CR 2–CR 5.
- Factor 5 requires a monitoring process that covers compliance with all policies and procedures described in factors 1–4.
HP 2022