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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11.15.2019 Mental Health Taxonomy Codes Why did NCQA include Mental Health taxonomy codes in the HEDIS 2020 Value Set Directory? Must we use those codes for transactional data?

The Mental Health Taxonomy Value Set was added in HEDIS 2020 to be used by organizations that report HEDIS using clinical (non-transactional) data. An organization that has taxonomy codes in transactional data may continue to map taxonomy codes not included in the VSD to taxonomy codes in the VSD, with auditor approval.

HEDIS 2020

11.15.2019 Transitions of Care - Notification of Inpatient Admission The medical record specification states, “Evidence that the information was filed in the EMR and is accessible to the PCP or ongoing care provider on the day of discharge or the following day meets criteria.” Should the reference to “discharge” in this sentence be changed to “admission”?

Yes. The sentence should be changed to read, “Evidence that the information was filed in the EMR and is accessible to the PCP or ongoing care provider on the day of admission or the following day meets criteria.”

HEDIS 2020

11.15.2019 System Generated Dates If during data collection an EHR system generates a date of the medical record report, may the system-generated date be used for medical record abstraction?

No. System generated dates during the data collection/abstraction process may not be used Organizations should use the documentation in the EHR to determine the date of service.

HEDIS 2020

11.15.2019 Comprehensive Diabetes Care Does documentation of “HB1c” meet criteria when reporting the HbA1c testing indicator?

Yes, documentation of " HB1c " is considered evidence of a HbA1c test and may be used when reporting the HbA1c testing indicator.

HEDIS 2020

11.15.2019 Plan All-Cause Readmissions The PCR measure indicates that for commercial and Medicaid, organizations report only members 18–64 years of age. This is inconsistent with Table PCR-1/2/3: Plan Population and Outlier Rate (Medicaid, Commercial and Medicare, 18+) and Table PCR-A-1/2/3 : Plan All-Cause Readmissions Rates Among Nonoutlier Members by Age (Medicaid, Commercial and Medicare, 18+), which indicate that members ages 18 and older are reported for all product lines. Are these data element tables incorrect for commercial and Medicaid reporting?

Yes, the tables are incorrect. When reporting the PCR measure for the commercial and Medicaid product lines, only include members 18–64 years of age. The age ranges 65–74, 75–84, 85+ and 65+ Total included in the data element tables are only collected for Medicare reporting.
For commercial and Medicaid reporting, collect 18–44, 45–54, 55–64 and 18–64 Total. 

HEDIS 2020

11.15.2019 Prenatal and Postpartum Care The Postpartum Care indicator states that documentation of “Resumption of physical activity and attainment of healthy weight” meets criteria. Does documentation need to include both resumption of physical activity AND attainment of healthy weight to meet criteria?

No. Documentation of either resumption of physical activity or attainment of healthy weight alone meets criteria.

HEDIS 2020

10.15.2019 Organization Responsibility for Chart Review HEDIS 2020 clarified that chart pursuit is recommended but is determined by the organization. Does this mean that chart pursuit is up to the organization?

Yes. Although NCQA recommends that organizations using the Hybrid Method pursue charts for all noncompliant members in the systematic sample, ultimately, the decision is the organization’s.

HEDIS 2020

10.15.2019 “Unknown” SES Category The SES stratification guidance in HEDIS 2020 Volume 2 indicates that the “Unknown” category may be used for only Puerto Rico plans or if the auditor approves a small number of unassigned members. Is there a specific number of Unknown members a plan is allowed to report?

Except for plans in Puerto Rico, which report all members in the “Unknown” category, it is expected that the member count in this category will be at or below 1%. If more than 1% of eligible members are assigned to the “Unknown” category, the plan must work with the auditor to identify why members are being categorized as “Unknown.”

HEDIS 2020

10.15.2019 Medication Dispensed Date If pharmacy data are classified as supplemental and the medication dispensed date is not documented, may the “shipped date” be used as the “dispensed date”?

No. The “shipped date” may not be used as “dispensed date” date when reporting the pharmacy measures.

HEDIS 2020

10.15.2019 Pharmacy Data and Medication Samples If pharmacy data are classified as supplemental, may the date when a provider gives free medication samples to a member be considered the “dispensed date”?

Yes. The date when the provider gives the medical sample to the member is considered the “dispensed date” when reporting pharmacy measures.
 

HEDIS 2020

10.15.2019 Codes Found in Medical Records For General Guideline 31: Supplemental Data, does removal of the hybrid data elements requirement mean that codes found in the medical record may be used as proof of service even if there is no additional documentation of the service provided?

No. Codes alone (without additional documentation of the service provided) do not meet criteria for proof of service. If a provider performs a service, it is expected that additional documentation exists in the medical record or in the primary source document. Auditors must validate, through primary source verification, all elements required by the administrative measure specification.

HEDIS 2020

10.15.2019 Reporting of the Initial Population by Data Source A bullet in the Summary of Changes in the DRR, AIS and PRS measures states: Removed the collection of the “Initial Population” and “Denominator” data elements by SSoR in the Data Elements for Reporting tables. This contradicts the Data Elements tables of all three measures, which has the initial population reported by data source. Is the SOC correct?

No. Replace the language with: Removed the collection of the “Denominator” data element by SSoR in the Data Elements for Reporting tables. The Data Elements tables are correct for the DRR, AIS and PRS measures and the initial population is reported by data source.

HEDIS 2020