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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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12.15.2019 PHM 1 Element B - Delegation vs Vendor Arrangements PHM 1, Element B is listed in Appendix 2 as an element where a vendor relationship may exist. The “Related information” section also includes information about the use of vendors in this element; however, it is unclear what functions NCQA considers delegation and what it considers a vendor relationship. Please clarify.

For PHM 1, Element B, NCQA evaluates communicating information to members who become eligible for programs that involve interactive contact.

Therefore, for any program that involves interactive contact (e.g., CCM, wellness coaching, web-based tools, disease management, smoking cessation classes), if the organization under review (e.g., a plan) contracts with another organization (e.g., a PHM company) to perform the function and the PHM company is responsible for communicating the information required to meet PHM 1, Element B, the plan has delegated the functions associated with PHM 1, Element B. This is considered delegation and all delegation requirements, including oversight, apply.

If the PHM company provides a technology supported service, such as a web-based tool, this is a vendor relationship for any requirements that directly evaluate the PHM function (e.g., PHM 4).

HP 2020

12.03.2019 AC 03 How does NCQA define “regular business hours”? Our practice is open from 8 am–5 pm. Would opening from 7 am–4 pm meet the requirements of this criterion?

By “regular business hours,” NCQA means 8 am-5 pm, Monday-Friday. The practice determines its hours of operation. Offering appointments between 7am and 4pm meets the criterion. The intent is that practices provide appointments outside typical business hours, to accommodate patients’ access needs. A practice could also shift staff hours—some staff work from 7 am-4 pm weekdays; some staff work from 8 am-5 pm weekdays—to enhance access.

PCMH 2017

12.02.2019 Prenatal and Postpartum Care The PPC measure defines an enrollment segment as a period of continuous enrollment with no gaps. The “last enrollment segment” is used in calculating the timelines of prenatal care numerator and is defined as the enrollment segment during the pregnancy with a start date closest to the delivery date. How do organizations identify the last enrollment segment for a member who has multiple enrollment segments?

For HEDIS 2020 reporting, enrollment segments are determined based on enrollment data provided by the health plan. If a plan provides the member's enrollment in different products/product lines as different enrollment segments, or even enrollment in the same product/product lines as different enrollment segments, the start date of the last enrollment segment must be used.

HEDIS 2020

12.02.2019 General Guideline 33: Measures That Require Results From the Most Recent Test or Measurement With General Guideline 33, organizations must use the most recent date when multiple dates of service for the same lab test are provided within a 7-day period. Which test is used in the following example, the September test or the December test?
A HbA1c lab claim on 12/30/2019 had a result date in the medical record on 1/3/2020. The member also had an HbA1c test with both the test and a result on 9/30/19.

Using General Guideline 33, the 12/30/2019 test is used as the most recent test while the 1/3/2020 result is within 7 days of the test, it is after the date threshold in the measure and may not be used. The result is counted as missing and the member is compliant for the HbA1c Testing and HbA1c Poor Control indicators. The member is not compliant for the HbA1c Control <7 for Selected Populations and HbA1c Control <8 indicators.
The 9/30/2019 test cannot be used as it is not the most recent.  

Note: Ensuring results in the year after the measurement year are not counted is not tested in HEDIS 2020 Measure Certification. 

HEDIS 2020

12.02.2019 Potentially Harmful Drug-Disease Interactions in Older Adults In the DDE measure, the IESD definition states, “For an acute inpatient encounter identified only by a professional claim (where the discharge date cannot be determined), the IESD is the date of service.” However, the definition does not specify which date to use as the IESD for nonacute inpatient encounters. Which date should be used?

Use the date of service to identify the IESD for nonacute inpatient encounters.

HEDIS 2020

12.02.2019 General Guideline 37: Measures That Use Medication Lists General Guideline 37 states that if an organization uses both pharmacy data (NDC codes) and clinical data (RxNorm codes) for reporting, to avoid double counting, deduplicate and count an NDC code and an RxNorm code for the same drug on the same date of service as only one dispensing event. If a measure specification says, “if multiple prescriptions for the same medication are dispensed on the same day, sum the days supply,” should the days supply from the pharmacy data event and the clinical data event be summed?

The intent of GG 37 is to prevent double-counting when an organization uses both pharmacy data (NDC codes) and clinical data (RxNorm codes) for reporting, because the same dispensing event can have both an NDC code in the pharmacy data and an RxNorm code in the clinical data. Because the two codes identify the same dispensing event (not two dispensing events), count an NDC code and an RxNorm code on the same date of service as one dispensing event and do not sum the days supply.

HEDIS 2020

12.02.2019 The “Route” column in the Asthma Medication Ratio and Medication Management for People With Asthma measures In the Asthma Controller Medications table and the Asthma Reliever Medications table (in the AMR and MMA measure specifications), what is the “Route” column used for?

Use the “Route” information from the tables to apply the “Definitions” for calculating an “inhaler dispensing event” and an “injection or intravenous dispensing event.” For routes listed as “subcutaneous” or “intravenous,” use the “injection or intravenous dispensing event” definition.
Note: In the MLD, the “Route” column lists “subcutaneous” and “intravenous” as “injection.”

HEDIS 2020

12.02.2019 Use of High-Risk Medications in Older Adults Why is NDC code 50090096201 included on both the Digoxin .25 mg Medications List and the Digoxin .125 mg Medications List?

NDC codes can be used to identify different medications at different points in time. The NDC code 50090096201 identified digoxin .125 mg until July 2017 and was reassigned to digoxin .25 mg in 2019. The code is included in both lists because of the time frame NCQA used for removing obsolete NDC codes (the look-back period for the measure plus two additional years).
Because it is likely that the code on a claim during the calendar year indicates digoxin .25 mg and because this issue may impose confusion when programming the measure, organizations may elect to remove the NDC code from the Digoxin .125 mg Medications List for HEDIS 2020 reporting. Measure Certification will only test this code as part of the Digoxin .25 mg Medications List.

HEDIS 2020

12.02.2019 General Guideline 50: Mapping Proprietary or Other Codes Organizations may map NDC or RxNorm codes based on generic name (or brand name), strength/dose and route. What information is used to map “dose” or “route”?

For mapping purposes, the organization must demonstrate that the medication being mapped is the same as a medication listed in the Medication List Directory (MLD). For example, the route for “benralizumab” is listed as “subcutaneous” in the Asthma Controller Medications table (p. 153 HEDIS 2020 Volume 2).
The MLD contains two generic products for benralizumab: “1 ML benralizumab 30 MG/ML Prefilled Syringe” and “benralizumab 30 MG/ML Prefilled Syringe,” where the Route is listed as “injection.” Therefore, it would be appropriate to map a code with the generic name “benralizumab” and strength “30 MG/ML and dose form or route of either “syringe” or “prefilled syringe” or “injection.”
Another example is fluticasone, which is listed as “inhalation” in the Asthma Controller Medications table. The MLD (Generic Product Name) identifies appropriate dose/forms as “metered dose inhaler” or “dry powder inhaler,” and lists the route as “inhalation.” Therefore, it would be appropriate to map codes for fluticasone if the strength/dose matches one in the MLD and if the dose form or route is “inhaler” or “metered dose inhaler” or “powder inhaler” or “inhalation.” It would not be appropriate to map codes for fluticasone with dose form or route of “nasal spray.”

HEDIS 2020

11.15.2019 Transitions of Care - Receipt of Discharge Information The Note in the medication record specification states, “Evidence that the PCP or ongoing care provider communicated with the ED about the admission meets criteria.” Should the reference to “admission” in this sentence be changed to “discharge”?

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 discharge or the following day meets criteria.”

HEDIS 2020

11.15.2019 Well-Child Visits in the First 15 Months of Life Should the “Number of required exclusions” row be removed from the Data Elements Table in the Well-Child Visits in the First 15 Months of Life (W15) measure?

Yes. Remove the “Number of required exclusions” row in the Data Elements Table.

Exchange 2020

11.15.2019 General Guideline 37 General Guideline 37 states that if organizations use both pharmacy data (NDC codes) and clinical data (RxNorm codes) for reporting, they should deduplicate and count an NDC code and an RxNorm code for the same drug on the same date of service as only one dispensing event, to avoid double counting. How should organizations handle this where different drugs are included in the same medication list with no variable to differentiate between “same or different”?

For measures where different drugs are included in the same medication list with no variable to differentiate between “same or different,” the organization develops its own method. It is appropriate for the organization to assume that an NDC code and an RxNorm code on the same date of service are for the “same drug” and count as one dispensing event; however, this will not be tested as part of measure certification.

HEDIS 2020