Categorize members in the “Any Services” category based on their age as of the first eligible encounter in any service category.
HEDIS 2019
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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12.14.2018 Identification of Alcohol and Other Drug Services and Mental Health Utilization In the “Any Service” category, how should we count members who have had eligible services in different age groups?
12.14.2018 Mental Health Utilization When reporting ED or observation visits the measures states to exclude ED/observation visits that result in an inpatient stay. Should the ED/observation visit be excluded if the inpatient stay does not contain a principal mental health diagnosis?
The intent of excluding ED/observation visits that result in an inpatient stay is to not double count events. For example, an ED visit with a principal mental health diagnosis that resulted in an inpatient stay for a principal diagnosis of mental health is reported only once in the “Inpatient Stay” category. An ED visit with a principal mental health diagnosis that resulted in an inpatient stay with a principal diagnosis for something other than mental health (e.g., heart attack) is reported only once in the “ED” category.
HEDIS 2019
12.14.2018 SES Guidelines* To calculate a member’s SES stratification, the instructions say to use the Monthly Membership Detail Data Files (MMDDF) for the measurement year to assess the member’s LIS, DE payment status. We find that in some months, members have multiple rows of data in the MMDDF, which represent adjustments for previous months. What should we do in this situation; is there a better file to use for determining SES?
Because the SES assessment is new and requires files not normally used for NCQA’s measure calculations, we have explored options for reporting members with these scenarios, and we think there are options for these data.
NOTE: NCQA’s Certification program tests one record per member based on the MMDDF.
- Option 1: If you are using MMDDF and one month has multiple rows for a member with different values in one row or more, sum the values and use the result to compare to the other 3 months. Remember that what is important is whether the number is > 0 or it is < or = 0. See this example:
| Member | RunDate | LisPremiumSubsidy |
| 1 | 2018 10 12 | 0000.00 |
| 1 | 2018 10 12 | 0035.50 |
| 1 | 2018 11 08 | 0035.50 |
| 1 | 2018 11 08 | -0035.50 |
| 1 | 2018 11 08 | 0035.50 |
| 1 | 2018 12 08 | 0035.50 |
This member is counted as LIS eligible: the sum of October = 35.50, the sum of November = 35.5, and December = 35.50 (all months are >0).
- Option 2: If you have access to the LIS History (LISHIST) File, it can be used to determine LIS eligibility. CMS describes the file as the most complete picture of LIS eligibility over a period not to exceed 36 months. This data file includes LIS activity for past, present and future enrollees. A full copy of the Plan-Communications-User-Guide-v122-August-31-2018, which describes the file, can be found at https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/Plan-Communications-User-Guide-v122-August-31-2018.pdf. Below is an example of the corresponding records in the LISHIST file for the member shown above.
| Member | LowIncomePeriodStartDate | LowIncomePeriodEndDate | LipsPercentage | PremiumLisAmount | ContractYear |
| 1 | 2016 09 01 | 2016 12 31 | 100 | 36.00 | 2016 |
| 1 | 2017 01 01 | 2017 12 31 | 100 | 36.00 | 2017 |
| 1 | 2018 01 01 | 100 | 35.50 | 2018 |
This file clearly shows that the member was LIS eligible for the HEDIS 2019 measurement year (calendar year 2018). If you have access to this file, it may be the easiest, most accurate data to use.
NOTES:
- If the LowIncomePeriodEndDate is blank, the member is still eligible.
- Plans should use a copy of this file from December 2018 or later.
*This same FAQ was posted on November 15, 2018 but was updated in the December 2018 FAQ posting. In the above “NOTES” section, it used to read that plans should use a copy of the file from January 2019 or later. This date was corrected to December 2018 or later.
HEDIS 2019
12.14.2018 ECDS Are EMRs the best data source for HEDIS ECDS measures? Do they contain all the information needed to report the measures?
EMRs are limited in the amount of longitudinal information they contain for any one patient. Many data sources meet ECDS requirements. Plans have access to a wealth of information from across a much larger network than any single provider. ECDS is designed to encourage plans and providers to seek alternative sources of data (already being collected) to fill gaps in knowledge about a person’s health care experiences and future requirements.
HEDIS 2019
12.14.2018 Appendix 3: PCP Definition May rural health centers be mapped to the PCP definition in Appendix 3 of Volume 2, similar to how Federally Qualified Heath Centers are handled?
11.15.2018 Transitions of Care When reporting the Patient Engagement After Inpatient Discharge indicator, if the member is unable to communicate with the provider, does an interaction between the member’s caregiver and the provider meet criteria?
11.15.2018 All ECDS Measures What is Source of Payment (SOP) Typology?
The Source of Payment Typology was developed to create a standard for classifying payer type. In measure specifications, it will enhance identification of specific payer identity in clinical data used for NCQA reporting.
Modeled loosely after the ICD typology for classifying medical conditions, the SOP Typology identifies broad payer categories (step 2) with related subcategories that are more specific to a product (steps 3 and 4). The first digit of each code represents the organization providing the funds for care; subsequent digits provide more-specific information about the mechanism used to provide funds. This format provides the flexibility to either use payer codes at a highly detailed level or to roll up codes to broader categories for comparative analysis across payers and locations.
SOP Typology can be used by anyone to code the payment data source. Use of the payer classification may require a crosswalk of previous code lists to the new hierarchical payer typology.
Example steps for plan classification using SOP Typology:
1. Plan needing typology classification: Harvard Pilgrim Health
2. Determine main category for first digit: 5 (Commercial)
3. Determine subcategory for second digit: 1 (Managed Care Private)
4. Determine subcategory breakdown for third digit: 2 (PPO)
5. Assign final SOP classification code: 511 (Commercial Managed Care-HMO)
HEDIS 2019
11.15.2018 SES Guidelines To calculate a member’s SES stratification, the instructions say to evaluate whether the member’s LIS values (item 35) are the same or different in the last 3 months of continuous enrollment (CE). How do you determine if a value is the same or different?
A value is different if it is either < or = 0 OR > 0. For the last 3 months of the CE period:
- Count the member as receiving an LIS payment if 2 of the last 3 months are >0, even if the values are different.
Example:
October LIS = 35
November LIS = 40
December LIS = -35
October LIS = 35
November LIS = 40
December LIS = -35
- Count the member as NOT receiving an LIS payment if 2 of the last 3 months are < or = 0, even if the values are different.
Example:
October LIS = 0
November LIS = -35
December LIS = 35
October LIS = 0
November LIS = -35
December LIS = 35
HEDIS 2019
11.15.2018 Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis If a member is included in the ART measure due to a rule-out diagnosis, may the member be removed from the denominator based on medical record documentation indicating an incorrect diagnosis of rheumatoid arthritis?
No. Members may not be removed from HEDIS measures due to billing errors. HEDIS does allow removal of “valid data errors” if they can be substantiated through medical record documentation; however, this applies only to hybrid measures. Because the ART measure is administrative only, the use of valid data errors is not permitted, nor may supplemental be used as a substitute for claims data (to correct billing errors) or to identify valid data errors.
HEDIS 2019
11.15.2018 Hospitalization for Potentially Preventable Complications On page 458 under step 5 there are instructions for how the number of members in the eligible population data element is reported in IDSS. It states, “Enter these values in the reporting table (HPC-A-3).” However, in that table, the column titled “Members in the Eligible Population” is shaded gray, indicating that it is calculated by IDSS. Is the data element reported by the organization, or calculated by IDSS?
11.15.2018 Transitions of Care When reporting Receipt of Discharge Information, if the PCP or ongoing care provider is the discharging provider, are the requirements the same to meet numerator criteria?
11.15.2018 Transitions of Care When reporting Notification of Inpatient Admission and Receipt of Discharge Information indicators using an integrated EMR system, is a “received date” required in the EMR if the information was in the shared EMR on the day of admission/discharge or on the following day?
No. With a shared EMR, evidence that the information was filed/accessible by the PCP or ongoing care provider on the day of admission/discharge or the following day meets criteria for Notification of Inpatient Admission and Receipt of Discharge Information indicators. The organization is not required to find additional notation of a “received date” if it is evident that the information was in the shared EMR on the day of admission/discharge or the following day.
HEDIS 2019