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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12.15.2020 Follow-Up After Hospitalization for Mental Illness (FUH) What time frame should be used to identify acute and nonacute readmissions or direct transfers when identifying the event/diagnosis?

Use a 30-day period. Replace the reference to “7-day follow up period” with “30 days after discharge (the denominator event)” in both the “Acute readmission or direct transfer” and “Nonacute readmission or direct transfer” sections of the specification. This ensures that the same Eligible Population criteria are used for all organizations that report the FUH measure (regardless of product line).

**This FAQ applies to QRS MY 2020.

Exchange 2020

12.15.2020 Appropriate Testing for Pharyngitis (CWP) Is the denominator for the measure based on episodes or members?

The denominator is based on episodes, not on members. Add the following Note to the event/diagnosis after step 7:
Note: The denominator for this measure is based on episodes, not on members. All eligible episodes that were not excluded remain in the denominator.

**This FAQ applies to QRS MY 2020.

Exchange 2020

12.15.2020 Appropriate Testing for Pharyngitis (CWP) Is the episode date excluded if the member does not receive antibiotics on or up to three days after the Episode Date?

Yes, the episode date is excluded. Add the following text to the event/diagnosis after step 3:
Exclude Episode Dates if the member did not receive antibiotics on or up to three days after the Episode Date.

**This FAQ applies to QRS MY 2020.

Exchange 2020

12.15.2020 Use of Imaging Studies for Low Back Pain (LBP) Is a history of a kidney transplant a required exclusion for the measure?

Yes. In the seventh bullet of step 4 of the event/diagnosis, replace the seventh bullet with:
Major organ transplant. Major organ transplant (Organ Transplant Other Than Kidney Value Set; Kidney Transplant Value Set; History of Kidney Transplant Value Set) any time in the member’s history through 28 days after the IESD.

**This FAQ applies to QRS MY 2020.

Exchange 2020

11.16.2020 Emergency Department Utilization (EDU) Will the EDU measure be publicly reported in MY 2020?

No. The EDU measure was given first-year status for MY 2020 due to significant changes, including exclusion of high-frequency utilizers.

HEDIS 2021

11.16.2020 Transition of Care (TRC) For the Medication Reconciliation Post-Discharge indicator, documentation of the current medications with evidence that the member was seen for post-discharge hospital follow-up with evidence of medication reconciliation or review meets criteria. Does documentation of a post-op/surgery follow-up visit, without reference to the hospital stay, count as evidence that the provider is aware of the hospitalization?

No. Documentation of “post-op/surgery follow-up” without a reference to “hospitalization,” “admission” or “inpatient stay” does not imply there was a hospitalization and is not considered evidence that the provider was aware of the hospitalization.

HEDIS 2021

11.16.2020 Prenatal and Postpartum Care (PPC) Step 3 of the event/diagnosis states, “Determine if enrollment was continuous 43 days prior to delivery through 56 days after delivery, with no gaps.” Is this correct?

No. Replace this with, “Determine if enrollment was continuous 43 days prior to delivery through 60 days after delivery, with no gaps.”

Exchange 2020

11.16.2020 VSD for the Quality Rating System The same OID is listed for the Systolic Greater Than or Equal To 140 Value Set and the Systolic Less Than 140 Value Set in the QRS Value Set Directory. Is this correct?

No. The value set OID for the Systolic Greater Than or Equal To 140 in the QRS Value Set Directory is incorrect and should be changed to 2.16.840.1.113883.3.464.1004.1242.

Exchange 2020

10.15.2020 Osteoporosis Screening in Older Women A dispensed dementia medication (Dementia Medications List) is listed as an exclusion in the eligible population. What time frame is required for the dispensing event?

The measure specification contains a formatting error and “A dispensed dementia medication (Dementia Medications List)” is intended to be a dash under the second bullet: “Any of the following during the measurement year or the year prior to the measurement year (count services that occur over both years).”

HEDIS 2021

10.15.2020 Inclusion of Dental and Vision Denials and Appeals for UM File Review Should denials and appeals for dental and vision requests be included in the UM denial and appeal file review universes?

For all product lines, dental and vision requests covered under the organization's medical benefit are within the scope of medical necessity review and must be included for UM file review for denials (UM 4-7) and appeals (UM 9), as outlined in the file review instructions.
Dental and vision requests not covered under medical benefits are not within the scope of denial and appeal file review.

HP 2020

9.15.2020 Childhood Immunization Status (CIS) Does the live attenuated influenza vaccine (LAIV) vaccination have to be given on the child’s second birthday?

Yes. The LAIV vaccination only counts if it is administered on the child’s second birthday. The minimum age for LAIV is 2 years, so vaccines given before that age do not meet criteria. You can view the recommendation guidelines on the CDC website (https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf).

HEDIS 2021

9.15.2020 Controlling High Blood Pressure (CBP) and Comprehensive Diabetes Care (CDC) Do BP readings taken by the member need to meet the member-reported requirements included in General Guideline 39?

No. BPs taken by the member do not need to meet requirements for member-reported data described in General Guideline 39 (collected by a PCP or other specialist while taking the patient’s history). If the BP result is documented in the member’s medical record, it may be used to assess numerator criteria if the BP does not meet any exclusion criteria (bullets at the bottom of page 157 and 195 in HEDIS MY 2020 and MY 2021 Volume 2).

HEDIS 2021