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.
NCQA does not evaluate the validity or reliability of the measure in Element A, QI 3 and QI 4. In Element C, QI 3 and QI 4, NCQA evaluates the validity of the remeasurement relative to the initial measurement. For example, NCQA evaluates if sampling, timing or other methodological factors introduces bias or other issues of comparison when determining an intervention’s effectiveness.
HP 2020
NCQA does not evaluate the validity or reliability of the measure in Element A, CC 1 and CC 2. In Element D in CC 1 and Element C in CC 2, NCQA evaluates the validity of the remeasurement relative to the initial measurement. For example, NCQA evaluates if sampling, timing or other methodological factors introduces bias or other issues of comparison when determining an intervention’s effectiveness.
MBHO 2019
Yes, it is correct. The elimination of Element A does not affect the 2020 review of Element B: UM Timeliness Report. The expectation is that the report includes timeliness for both decision making and notification of the decision given that the report includes denials and approvals. NCQA does not require written notification for approvals; therefore, timeliness for approvals is only reported under decisions.
MBHO 2020
No. Only direct transfers during the 30-day follow-up period should be identified. A “direct transfer” is when the discharge date from the first acute inpatient or residential care setting precedes the admission date to a second acute inpatient or residential care setting by one calendar day or less.
If a member had a stay from January 1–5, followed by readmission on January 6 and discharge on January 8, this is considered a direct transfer and the January 8 discharge date is used for reporting.
If a member had a stay from January 1–5 and a stay from January 8–10, this is considered a readmission. The “multiple discharges, visits or events during in a 31-day period” rule applies; the January 5 discharge is used for reporting and the January 10 discharge is dropped.
HEDIS 2020
Yes. The first two bullets in Step 2 of the Event/Diagnosis are required exclusions and supplemental data may be used when reporting them. These exclusions are reported in the “Number of required exclusions” data element in IDSS. The remainder of the bullets in Step 2 are exclusions, but they are not required exclusions and supplemental data may not be used when reporting them.
HEDIS 2020
The purpose of same-or-similar specialist review of appeals is to apply specific clinical knowledge and experience when determining if an appeal meets criteria for medical necessity and clinical appropriateness. “Training and experience” refers to the practitioner’s clinical training and experience.
The intent is that the specialist reviewing the appeal would have encountered a patient with this condition who is considering or has received the service or procedure in a clinical setting. NCQA assesses whether the specialist is appropriate for the condition, service or procedure in question, and does not consider the referring practitioner type.
Effective January 1, 2020, NCQA accepts board certification in the same specialty as a proxy for clinical training and experience.
NCQA does not require that the same-or similar specialist reviewer be actively practicing.
Experience with the condition, service or procedure that is limited to UM decision making in cases similar to the appeal in question is not considered sufficient experience, nor do UM decision-making criteria supersede the requirement for same-or-similar specialist review.
UM-CR-PN 2020
