FAQ Directory

  The optional exclusion criteria may be applied only if the member did not have a diagnosis of diabetes during the measurement year or the year prior to the measurement year. If the member was included in the measure based on claim or encounter data, as described in the event/diagnosis criteria, the optional exclusions do not apply because the member had a diagnosis of diabetes. If the member was included in the measure based on pharmacy data alone, the member may meet criteria for an optional exclusion if no diagnosis of diabetes was found in claim or encounter data or in the medical record.

For example, if a member was included in the measure based on pharmacy data but had a visit with a diagnosis of diabetes, the member does not meet optional exclusion criteria.

If a member was included in the measure based on pharmacy data alone and there was no claim or encounter with a diagnosis of diabetes, but medical record documentation indicated the member is a diabetic, the member does not meet optional exclusion criteria.

If a member was included in the measure based on pharmacy data alone and there was no claim or encounter with a diagnosis of diabetes and no evidence of diabetes in the medical record being reviewed, the member may meet optional exclusion criteria if there was a diagnosis of polycystic ovaries any time during the member’s history through December 31 of the measurement year, or a diagnosis of gestational diabetes or steroid-induced diabetes during the measurement year or the year prior to the measurement year.

HEDIS 2015

An organization that does not have a voicemail system should have other means for identifying member calls after normal business hours, and return members’ call on the next business day.​

Yes. If an organization informs NCQA that it follows the Affordable Care Act requirements for external reviews (PHS Act section 2719), UM 8, Element E applies, even if the state where the organization operates does not comply with federal regulations.

To determine if a stay should be excluded, identify the index hospitalization and the FIRST readmission (if there is one). If the FIRST readmission was planned for, drop the index.

So, for example 2:

Stay 1. Index hospitalization with unplanned readmission (stay 2): Include as index.
Stay 2. Index hospitalization with planned readmission (stay 3): Drop as index.
Stay 3. Index hospitalization with planned readmission (stay 4): Drop as index.
Stay 4. Index hospitalization with no readmission: Include as index.

Stay 1 is the index. Stay 2 is the first readmission to assess, but because it does not meet criteria for a “planned hospital stay,” stay 1 is not excluded.

HEDIS 2015

No, if a problem list is found in an office visit note then it would be considered a dated problem list and the date of the visit must be used. A true problem list is a standalone document in the medical record that records a member’s conditions. It is typically located in a centralized section of the medical record (usually the front of the chart) and lists all diagnoses. In an EHR a problem list is present at all routine office visits.

If the documentation is part of the member’s medical history, progress note or office visit note, the date of the visit must be used as the date of the HTN confirmation and must be on or before June 30 of the measurement year. The representative BP reading must occur after the date when the diagnosis of HTN was confirmed.

HEDIS 2015

General Guideline 28 outlines the requirements for using member-reported supplemental data, which may be accepted only when accompanied by proof-of-service documentation from the legal health record. If proof-of-service documentation is not available, member-reported information on services rendered (patient history) are acceptable only if taken by a PCP as part of the member’s history. Information must be signed, dated and maintained in the member’s legal health record. General Guideline 29: Date Specificity addresses measures that include date requirements in order to achieve numerator compliance. Dates must be specific enough to determine that the event occurred during the period specified by the measure. 

IHA 2013

Yes, if the flat copay amount is specified on the organization’s Web site. Members must have no additional financial liability (i.e. co-insurance, deductibles, charges in excess of allowed amounts, differentials in cost between in-network care and out-of-network care, costs that vary for the formulary) for services and cannot be balance-billed by a practitioner, provider or other party.

This exception does not apply to Element B in MEM 3 and 5.

For Marketplace (Exchange) products, HEDIS will follow the federal Marketplace Quality Rating System (QRS). CMS will release QRS measure specifications and reporting guidelines (including HEDIS) in September 2014.

Exchange 2015

Yes. The 45-calendar day notice period for providing results and providing an opportunity for a physician to request a correction or change applies to each cycle of measurement and action an organization takes, regardless of frequency (e.g., biannual, annual, semiannual, quarterly); however, if an organization recalculates results without changing its methodology or measures, it does not need to provide the methodology again as long as it supplies information on how to obtain that methodology.

The exception to the minimum 45-calendar-day notice period for action is when the action involves only pay-for-performance activities that are not publicly reported (e.g., an action that is only between the organization and the physician). In this instance, the organization may provide the results and methodology concurrent with additional or bonus payment. It must still provide a process for the physician to request corrections or changes.

No. Because of the delay in ICD-10 implementation, ICD-10 codes will not be used during P4P MY 2014 and therefore will not be included in the P4P MY 2014 Value Set Directory.

Purchasers of the P4P MY 2014 Value Set Directory will receive a separate file with ICD-10 codes proposed for inclusion in future releases of P4P specifications, but the codes will not be considered part of the MY 2014 measure specifications.

IHA 2013

Thank you for bringing this to our attention. When converting coding table references to value set references, the Option A UBTOB language and Option B POS language was inadvertently omitted. For OSU, Options A and B should include both POS and UB Type of Bill codes and should read as follows:

Any of the following code options meet criteria:

· Option A: Ambulatory Surgery Option A Value Set with Ambulatory Surgery POS Value Set .

· Option A: Ambulatory Surgery Option A Value Set with Ambulatory Surgery UBTOB Value Set.

· Option B: Ambulatory Surgery Procedure Value Set with Ambulatory Surgery UBREV Value Set and Ambulatory Surgery UBTOB Value Set.

· Option B: Ambulatory Surgery Procedure Value Set with Ambulatory Surgery UBREV Value Set and Ambulatory Surgery POS Value Set.

This will be corrected in the next release of the manual.

IHA 2013

No. The HEDIS 2015 Value Set Directory will not include invalid ICD-9 codes; it will only include ICD-9 codes that are valid for billing. The HEDIS 2014 value sets included invalid ICD-9 codes; these will be removed, effective with HEDIS 2015.

HEDIS 2014