Categorize members in the “Any Services” category based on their age as of the first eligible encounter in any service category.
HEDIS 2019
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.
The intent of excluding ED/observation visits that result in an inpatient stay is to not double count events. For example, an ED visit with a principal mental health diagnosis that resulted in an inpatient stay for a principal diagnosis of mental health is reported only once in the “Inpatient Stay” category. An ED visit with a principal mental health diagnosis that resulted in an inpatient stay with a principal diagnosis for something other than mental health (e.g., heart attack) is reported only once in the “ED” category.
HEDIS 2019
Because the SES assessment is new and requires files not normally used for NCQA’s measure calculations, we have explored options for reporting members with these scenarios, and we think there are options for these data.
NOTE: NCQA’s Certification program tests one record per member based on the MMDDF.
Member | RunDate | LisPremiumSubsidy |
1 | 2018 10 12 | 0000.00 |
1 | 2018 10 12 | 0035.50 |
1 | 2018 11 08 | 0035.50 |
1 | 2018 11 08 | -0035.50 |
1 | 2018 11 08 | 0035.50 |
1 | 2018 12 08 | 0035.50 |
This member is counted as LIS eligible: the sum of October = 35.50, the sum of November = 35.5, and December = 35.50 (all months are >0).
Member | LowIncomePeriodStartDate | LowIncomePeriodEndDate | LipsPercentage | PremiumLisAmount | ContractYear |
1 | 2016 09 01 | 2016 12 31 | 100 | 36.00 | 2016 |
1 | 2017 01 01 | 2017 12 31 | 100 | 36.00 | 2017 |
1 | 2018 01 01 | 100 | 35.50 | 2018 |
This file clearly shows that the member was LIS eligible for the HEDIS 2019 measurement year (calendar year 2018). If you have access to this file, it may be the easiest, most accurate data to use.
NOTES:
*This same FAQ was posted on November 15, 2018 but was updated in the December 2018 FAQ posting. In the above “NOTES” section, it used to read that plans should use a copy of the file from January 2019 or later. This date was corrected to December 2018 or later.
HEDIS 2019
EMRs are limited in the amount of longitudinal information they contain for any one patient. Many data sources meet ECDS requirements. Plans have access to a wealth of information from across a much larger network than any single provider. ECDS is designed to encourage plans and providers to seek alternative sources of data (already being collected) to fill gaps in knowledge about a person’s health care experiences and future requirements.
HEDIS 2019
The Source of Payment Typology was developed to create a standard for classifying payer type. In measure specifications, it will enhance identification of specific payer identity in clinical data used for NCQA reporting.
Modeled loosely after the ICD typology for classifying medical conditions, the SOP Typology identifies broad payer categories (step 2) with related subcategories that are more specific to a product (steps 3 and 4). The first digit of each code represents the organization providing the funds for care; subsequent digits provide more-specific information about the mechanism used to provide funds. This format provides the flexibility to either use payer codes at a highly detailed level or to roll up codes to broader categories for comparative analysis across payers and locations.
SOP Typology can be used by anyone to code the payment data source. Use of the payer classification may require a crosswalk of previous code lists to the new hierarchical payer typology.
Example steps for plan classification using SOP Typology:
1. Plan needing typology classification: Harvard Pilgrim Health
2. Determine main category for first digit: 5 (Commercial)
3. Determine subcategory for second digit: 1 (Managed Care Private)
4. Determine subcategory breakdown for third digit: 2 (PPO)
5. Assign final SOP classification code: 511 (Commercial Managed Care-HMO)
HEDIS 2019
A value is different if it is either < or = 0 OR > 0. For the last 3 months of the CE period:
HEDIS 2019
No. Members may not be removed from HEDIS measures due to billing errors. HEDIS does allow removal of “valid data errors” if they can be substantiated through medical record documentation; however, this applies only to hybrid measures. Because the ART measure is administrative only, the use of valid data errors is not permitted, nor may supplemental be used as a substitute for claims data (to correct billing errors) or to identify valid data errors.
HEDIS 2019
No. With a shared EMR, evidence that the information was filed/accessible by the PCP or ongoing care provider on the day of admission/discharge or the following day meets criteria for Notification of Inpatient Admission and Receipt of Discharge Information indicators. The organization is not required to find additional notation of a “received date” if it is evident that the information was in the shared EMR on the day of admission/discharge or the following day.
HEDIS 2019