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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2.15.2020 UM Timeliness Report Under 2020 HPA standards, UM 5, Element D requires organizations to monitor UM decision making and notification using UM 5 decision time frames, even though UM 5, Elements A, C and E were eliminated under the 2020 standards. Is this correct?

Yes, it is correct. The elimination of Elements A, C and E does not affect the review of Element D: UM Timeliness Report. The expectation is that the report includes timeliness for both decision making and notification of the decision given that the report includes denials and approvals. NCQA does not require written notification for approvals; therefore, timeliness for approvals is only reported under decisions.

UM-CR-PN 2020

2.15.2020 UM Timeliness Report (MBHO) Under 2020 MBHO standards, UM 5, Element B requires organizations to monitor UM decision making and notification using UM 5 decision time frames, even though UM 5, Element A was eliminated under the 2020 standards. Is this correct?

Yes, it is correct. The elimination of Element A does not affect the 2020 review of Element B: UM Timeliness Report. The expectation is that the report includes timeliness for both decision making and notification of the decision given that the report includes denials and approvals. NCQA does not require written notification for approvals; therefore, timeliness for approvals is only reported under decisions.

MBHO 2020

2.15.2020 Measure Validity The explanation in Element A in QI 3 and QI 4 does not require that data collected results be valid or reliable measures; however, the explanation for Element C in QI 3 and QI 4 states that the organization must describe its methodology (numerator, denominator, sampling, measurement periods). Does NCQA review the validity and reliability of measure results in either Element A or C?

NCQA does not evaluate the validity or reliability of the measure in Element A, QI 3 and QI 4. In Element C, QI 3 and QI 4, NCQA evaluates the validity of the remeasurement relative to the initial measurement. For example, NCQA evaluates if sampling, timing or other methodological factors introduces bias or other issues of comparison when determining an intervention’s effectiveness.

HP 2020

2.15.2020 Measure Validity (MBHO) The explanation in Element A in CC 1 and CC 2 does not require that data collected results be valid or reliable measures; however, the explanation for Element D in CC 1 and Element C in CC 2 states that the organization must describe its methodology (numerator, denominator, sampling, measurement periods). Does NCQA review the validity and reliability of measure results in either Element A, C or D?

NCQA does not evaluate the validity or reliability of the measure in Element A, CC 1 and CC 2. In Element D in CC 1 and Element C in CC 2, NCQA evaluates the validity of the remeasurement relative to the initial measurement. For example, NCQA evaluates if sampling, timing or other methodological factors introduces bias or other issues of comparison when determining an intervention’s effectiveness.

MBHO 2019

2.14.2020 Follow-Up After High-Intensity Care for Substance Use Disorder Direct Transfer instructions state, “Identify direct transfers to an acute inpatient care or residential setting during the 30-day follow-up period.” Should readmissions during the 30-day period also be identified?

No. Only direct transfers during the 30-day follow-up period should be identified. A “direct transfer” is when the discharge date from the first acute inpatient or residential care setting precedes the admission date to a second acute inpatient or residential care setting by one calendar day or less.
If a member had a stay from January 1–5, followed by readmission on January 6 and discharge on January 8, this is considered a direct transfer and the January 8 discharge date is used for reporting.
If a member had a stay from January 1–5 and a stay from January 8–10, this is considered a readmission. The “multiple discharges, visits or events during in a 31-day period” rule applies; the January 5 discharge is used for reporting and the January 10 discharge is dropped.

HEDIS 2020

2.14.2020 Prenatal and Postpartum Care For members whose last enrollment start date is less than 42 days prior to delivery, should we include prenatal visits that occur after the delivery date but within 42 days after the enrollment start date?

No. The intent is to only count prenatal visits, which by definition can only occur prior to delivery. Do not count visits that occur on or after the date of delivery for the Timeliness of Prenatal Care indicator.

HEDIS 2020

1.15.2020 Controlling High Blood Pressure The CBP measure lists the following exclusions in the eligible population:

• Medicare members 66 years of age and older as of December 31 of the measurement year who meet either of the following:
– Enrolled in an Institutional SNP (I-SNP) any time during the measurement year.
– Living long-term in an institution any time during the measurement year 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 year.

Should these exclusions be removed from the CBP measure specifications?

Yes. Remove the bullets that include I-SNP and LTI exclusions for Medicare members from the specifications. They are not intended for the Exchange population.

Exchange 2020

1.15.2020 Adherence to Antipsychotic Medications for Individuals With Schizophrenia Are the first two bullets below in Step 2: Exclusions of the Event/Diagnosis “required” exclusions?
• A diagnosis of dementia (Dementia Value Set).
• Did not have at least two antipsychotic medication dispensing events. There are two ways to identify dispensing events: by claim/encounter data and by pharmacy data. The organization must use both methods to identify dispensing events, but an event need only be identified by one method to be counted.
– Claim/encounter data. An antipsychotic medication (Long Acting Injections 14 Days Supply Value Set; Long Acting Injections 28 Days Supply Value Set; Long Acting Injections 30 Days Supply Value Set).
– Pharmacy data. Dispensed an antipsychotic medication on an ambulatory basis. Use all the medication lists in the Oral Antipsychotic Medications and Long-Acting Injections tables below to identify antipsychotic medication dispensing events.

Yes. The first two bullets in Step 2 of the Event/Diagnosis are required exclusions and supplemental data may be used when reporting them. These exclusions are reported in the “Number of required exclusions” data element in IDSS. The remainder of the bullets in Step 2 are exclusions, but they are not required exclusions and supplemental data may not be used when reporting them.

HEDIS 2020

1.15.2020 Denial Notifications to members via web portals If an organization uses a member web portal as a means of member written/electronic denial notification (which includes all requirements of UM 4 through UM 7), does this meet the UM denial notification requirements?

No, notification of denials to a member through a web portal does not meet the requirement for member notifications. However, emailing a denial notification directly to a member would be acceptable for electronic notification.

MBHO 2020

1.15.2020 “Training and Experience” for Same or Similar Specialists Please clarify what is meant by “training and experience” for same or similar specialist in UM 8 and UM 9.

The purpose of same-or-similar specialist review of appeals is to apply specific clinical knowledge and experience when determining if an appeal meets criteria for medical necessity and clinical appropriateness. “Training and experience” refers to the practitioner’s clinical training and experience.
The intent is that the specialist reviewing the appeal would have encountered a patient with this condition who is considering or has received the service or procedure in a clinical setting. NCQA assesses whether the specialist is appropriate for the condition, service or procedure in question, and does not consider the referring practitioner type.

Effective January 1, 2020, NCQA accepts board certification in the same specialty as a proxy for clinical training and experience.
NCQA does not require that the same-or similar specialist reviewer be actively practicing.

Experience with the condition, service or procedure that is limited to UM decision making in cases similar to the appeal in question is not considered sufficient experience, nor do UM decision-making criteria supersede the requirement for same-or-similar specialist review.

MBHO 2020

12.16.2019 Childhood Immunization Status The third bullet in the Rotavirus numerator description references Rotavirus (2 Dose Schedule) Procedure Value Set, which does not exist in the Value Set Directory. Which value set should be used for reporting?

Replace the value set reference with “Rotavirus Vaccine (2 Dose Schedule) Procedure Value Set” and use this value set for reporting.

HEDIS 2020

12.16.2019 Follow-Up Care for Children Prescribed ADHD Medication The third bullet in the Rate 2-C&M Phase numerator description references the Observation Visit Value Set, which does not exist in the Value Set Directory. Which value set should be used for reporting?

Replace the value set reference with “Observation Value Set” and use this value set for reporting.

HEDIS 2020