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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10.15.2021 Transitions of Care The TRC measure includes a summary of change (SOC) to indicate that it the value is stratified. Should this be removed from the SOC?

Yes. Remove the SOC text that reads, “Revised the Reporting Instructions for the ‘NumeratorByAdminElig’ data element in Table TRC-3: Data Elements for Transitions of Care to ‘For each Metric and Stratification.’” Organizations reported “NumeratorByAdminElig” by age stratification in the past, so this is not a change to the measure for MY 2020 & MY 2021 reporting.

HEDIS 2022

9.15.2021 Well-Child Visits in the First 30 Months of Life (W30) Does a well child visit with an OB/GYN meet criteria for the W30 measure?

Yes, if the OB/GYN is considered to be a PCP by the health plan (i.e., offers primary care medical services). Refer to Appendix 3 of HEDIS Measurement Year 2022 for the definition of “PCP.”

HEDIS 2022

9.15.2021 General Guideline 33: Race and Ethnicity Stratification May supplemental data be used for race and ethnicity stratifications?

Yes. Supplemental data may be used to identify race and ethnicity when stratifying the eligible population. 

HEDIS 2022

9.15.2021 Follow-Up After Emergency Department Visit for Substance Use (FUA) It appears that the medication tables for the Alcohol Use Disorder Treatment Medications List and the Opioid Use Disorder Treatment Medications List needed to identify pharmacotherapy dispensing events in the numerator are not included in the FUA measure. Where can they be found?

The medication tables for the Alcohol Use Disorder Treatment Medications List and the Opioid Use Disorder Treatment Medications List were inadvertently omitted from the measure specifications. The full medication lists are included in the MY 2022 Medication List Directory (MLD). The medication tables can also be found in the following measures: Follow-Up After High-Intensity Care for Substance Use Disorder, Identification of Alcohol and Other Drug Services, Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment.  

HEDIS 2022

9.15.2021 Notification of Internal Appeal to Member or Treating Practitioner Must an internal appeal notification be sent to both the member and the treating practitioner?

No. The internal appeal notification must be sent to the member.  

The UM 9, Element D stem incorrectly states that both the member and the treating practitioner must be notified. This will be corrected in November’s Policy Updates.

HP 2022

9.15.2021 Use of HIP Delegate and Virtual-Only Practitioner If an organization adds virtual-only practitioners to its network and utilizes an NCQA-Certified Health Information Product (HIP) delegate for directory requirements in HIP 4, must the delegate indicate “virtual only” on the directory?

Yes. The NCQA-Certified HIP delegate must indicate “virtual only” in the directory if there is not a physical office, to meet HIP 4. If the organization manages any part of the directory, “virtual only” must be indicated where applicable.

 

HIP 2016

9.15.2021 PCS Questions Do answers from the Policy Clarification Support system have an expiration date?

We recommend that organizations not use PCS responses that are over 3 years old. If a question relates directly to a measure specification or a general guideline that was revised from a previous measurement year, we recommend resubmitting the question.

HEDIS 2021

9.15.2021 Guidelines for Calculations and Sampling: Hybrid Method How should the eligible population be reported for hybrid measures if there are optional or required exclusions?

The eligible population for hybrid measures should be reported before the optional exclusions and after the required exclusions for all three hybrid method approaches (refer to Appendix 4 in HEDIS Volume 2). For example, if the eligible population is 100 members and 10 members met optional exclusion criteria, then the reported eligible population value must still be 100.

HEDIS 2020

9.15.2021 Acute Hospital Utilization, Emergency Department Utilization and Hospitalization for Potentially Preventable Complications May covariance values be rounded before using them in the variance calculation?

No. Do not round covariance values for use in variance calculations. Member-level PPD and PUCD should be unrounded in covariance and variance calculations, although truncation to 10 decimal points is applied, per the previous step. NCQA intends to evaluate truncation and rounding logic throughout intermediate calculations to ensure consistency and reduce potential bias in a future publication release.

HEDIS 2022

9.15.2021 Guidelines for Calculations and Sampling: Hybrid Method How should the eligible population be reported for hybrid measures if there are optional or required exclusions?

The eligible population for hybrid measures should be reported before the optional exclusions and after the required exclusions for all three hybrid method approaches (refer to Appendix 4 in HEDIS Volume 2). For example, if the eligible population is 100 members and 10 members met optional exclusion criteria, then the reported eligible population value must still be 100.

HEDIS 2022

9.15.2021 Acute Hospital Utilization, Emergency Department Utilization and Hospitalization for Potentially Preventable Complications May covariance values be rounded before using them in the variance calculation?

No. Do not round covariance values for use in variance calculations. Member-level PPD and PUCD should be unrounded in covariance and variance calculations, although truncation to 10 decimal points is applied, per the previous step. NCQA intends to evaluate truncation and rounding logic throughout intermediate calculations to ensure consistency and reduce potential bias in a future publication release.

HEDIS 2020

9.15.2021 Acute Hospital Utilization, Emergency Department Utilization and Hospitalization for Potentially Preventable Complications When should rounding occur for variance calculations?

The variance should not be rounded until the final step in the calculation. The final variance calculation for reporting should be rounded to four decimal places using the .5 rule. For example, the PPD and PUCD values are truncated to 10 decimal places, multiplied together at the member level and summed across members for the total. Round the total sum to four decimal places.

HEDIS 2020