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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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4.15.2021 Provisional Status Triggers In what circumstances will an organization receive Provisional status?

An organization will receive Provisional status if it:  
 

  1. Scores below 80% and above 55% of the maximum possible points in any Standards Category, or  

  1. Does not achieve an element score of “Met” in three or more must-pass elements.

HP 2020

4.15.2021 Provisional Status Triggers In what circumstances will an organization receive Provisional status?

An organization will receive Provisional status if it:  
 

  1. Has an overall standards score between 60 and 69.99, or  

  1. Does not achieve an element score of 80% in three or more must-pass elements.

MBHO 2021

4.15.2021 Evaluation Options for PHM 6, Element B Does PHM 6, Element B apply to First Surveys?

No. PHM 6, Element B applies only to Renewal Surveys. First Surveys are not required to meet this element and will receive an NA for 2020.

HP 2020

4.15.2021 Vendor Relationship: ME 2, Element A Are all the requirements in ME 2, Element A considered a vendor relationship if the organization utilizes a mail vendor for distribution?

No. For ME 2, Element A, only the distribution component of the requirement is considered a vendor relationship. 

As stated in the explanation, these elements may not be delegated. The organization must create the written information, but may distribute it through a mail vendor.

HP 2021

4.15.2021 Vendor Relationship: RR 3, Element A Are all the requirements in RR 3, Element A considered a vendor relationship if the organization utilizes a mail vendor for distribution?

No. For RR 3, Element A, only the distribution component of the requirement is considered a vendor relationship. 

As stated in the explanation, these elements may not be delegated. The organization must create the written information, but may distribute it through a mail vendor.

MBHO 2021

3.15.2021 CVO 5, Element A: NTIS Verification Source Is the National Technical Information Service (NTIS) an acceptable verification source for DEA under the 2016 CVO Standards and Guidelines?

No. Effective November 17, 2020, NTIS is no longer an acceptable source to verify a practitioner's DEA certificate. This FAQ was addressed in the 2021 CVO updates on 11/23/2020. Please see https://dea.ntis.gov for more information.

CVO 2016

1.15.2021 Transitions of Care (TRC) Volume 2 states that for MY 2021 reporting, the organization may reduce the sample size using the prior year’s audited, product line-specific rate. Which rate should organizations use for sample size reduction?

Organizations may reduce the sample size for the TRC measure based only on the prior year’s audited, product line-specific rate for the lowest rate among all reported TRC indicators.

HEDIS 2021

1.15.2021 General Guideline 15 When a member has dual enrollment in Medicaid/Medicare how long must the member be enrolled in Medicare (PFFS or primary Medicare enrollment in another organization) to be removed from the Medicaid product line?

There is no minimum enrollment requirement. Per General Guideline 15, members must meet the measure’s continuous enrollment requirements and be considered dually enrolled based on continuous enrollment criteria or the service date.
Organizations must follow General Guideline 15 with regard to assessing coverage and should review enough data to meet the measure specification requirement.

HEDIS 2021

1.15.2021 General Guideline 15 What is the time frame for assessing dual enrollment?

As stated in the General Guideline 15, the time frame is assessed by measure. For measures with continuous enrollment, dual enrollment is determined as of the end of the continuous enrollment period, or the last enrollment segment, if there is a gap at the end of the continuous enrollment period.
For measures without a continuous enrollment requirement, members must have dual enrollment on the date of service or the date of discharge.

HEDIS 2021

1.15.2021 General Guideline 15 What type of Medicare enrollment counts when assessing members with dual Medicaid and Medicare enrollment?

General Guideline 15 includes language about Medicare contracts required to report HEDIS. These are meant to indicate Medicare Part C or Medicare Parts A and B. Having only Medicare Part D does not qualify as coverage for dual enrollment.

HEDIS 2021

1.15.2021 Follow-Up After Hospitalization for Mental Illness (FUH) What value sets can be used to identify community mental health center visits (the fifth bullet in the Numerator)?

The fifth bullet in the Numerator is missing value set references. Replace the bullet text with:
A community mental health center visit (Visit Setting Unspecified Value Set; BH Outpatient Value Set; Observation Value Set; Transitional Care Management Services Value Set) with (Community Mental Health Center POS Value Set).

**This FAQ applies to QRS MY 2020.

Exchange 2020

1.05.2021 Utilization Measures & Enrollment by Product Line (ENP) Are members with unknown or third gender excluded from member months tables that only designate binary gender?

Yes. Members with unknown or non-binary gender are excluded from only the utilization measures that require a specific gender (male or female) and the ENP measure because this measure requires a gender to be assigned in the reporting tables. NCQA continues to track industry standards for non-binary gender.

*Originally posted on 11/16/2020, this FAQ was updated on 1/5/2021.  

HEDIS 2021