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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11.15.2018 Appeals covered in QI 6 What types of appeals are included in QI 6, coverage appeals (e.g., in UM 8–UM 9) or noncoverage appeals (e.g., in RR 2)?

QI 6 requires organizations to collect data from all sources of member complaints and appeals, including UM coverage appeals addressed in UM 8–UM 9 and noncoverage appeals addressed in RR 2.
Note: Data collected and analyzed before February 15, 2019, will be accepted as meeting the requirement even if not all types of appeals are included. Data collected and analyzed on or after this date must comply with the requirement stated in the FAQ.
If your organization collected and analyzed data before February 15, 2019, and interpreted the requirement as applying to only one type of appeal, notify the surveyor at the start of the survey so the misinterpretation does not affect scoring.
 

MBHO 2018

11.15.2018 General Guidelines Do standard supplemental data files need to contain all data elements required by the hybrid specification, regardless of the method used by the plan to report the measure?

Yes. As stated in General Guideline 30, both standard and nonstandard supplemental data files must contain all data elements required by the hybrid specification, regardless of the reporting method used (administrative or hybrid). However, for HEDIS 2019, NCQA makes an exception for only standard supplemental data files and for only the Adult BMI Assessment (ABA) and Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) measures.

Because the values (height, weight) used to calculate BMI are often stored in EMRs and not included in data extracts, NCQA does not want to penalize plans for not having these data elements in their data files. Auditors may approve standard supplemental data files that include only the date and the BMI value or percentile.

For the WCC nutrition and physical activity counseling indicators, a date of service and an applicable code from the VSD counts as compliant.

NCQA is evaluating the standard supplemental data requirement for all other hybrid measures for HEDIS 2020.

HEDIS 2019

10.15.2018 Standardized Healthcare-Associated Infection Ration The HEDIS® 2019 Volume 2 Technical Specifications Update announced the suspension of the Standardized Healthcare-Associated Infection Ration (HAI) measure for all product lines. This change causes a discrepancy between the CMS Reporting Memo and HEDIS 2019 Volume 2 Technical Specifications. Will CMS clarify what must be reported for HEDIS 2019 for Medicare?

Yes. CMS released a clarification, through Health Plan Management System (HPMS) on October 12, 2018, that HAI has been suspended and is not required for HEDIS 2019 reporting. If you have additional questions about CMS requirements, contact HEDISquestions@cms.hhs.gov.

HEDIS 2019

10.15.2018 80% must-pass threshold for UM elements Because NCQA raised the UM must-pass threshold from 50% to 80%, will NCQA create an 80% scoring option for requirements without such a scoring option?

No. To keep scoring simple, NCQA set a threshold of 80% or higher for all UM must-pass elements, rather than setting a specific threshold for each element based on its scoring options. If an element does not have an 80% option, the “or higher” applies. Keep in mind that an organization may miss the requirements for a few files and still score 100% on the element. For additional information on file review scoring, refer to the scoring table in each element or to the file review worksheet in the Interactive Review Tool (IRT).

UM-CR-PN 2019

10.15.2018 Proportion of Days Covered Should the upper and lower Confidence Interval data elements be removed from the reporting tables in the Proportion of Days Covered (PDC) measure?

Yes. NCQA removed confidence intervals from all measures and data collection (IDSS) in HEDIS 2019; this applies to all related products using IDSS, including the QRS PDC measure.
Organizations that want to calculate or use confidence intervals must use the other data element fields and calculate confidence intervals for internal analysis.

Exchange 2019

10.15.2018 Required Exclusions Are members who are excluded because of hospice, advanced illness, frailty, Institutional SNP (I-SNP) or living long-term in an institution (LTI) included in the “Number of required exclusions” data element?

No. Only members who meet the criteria in the section of the measure labeled “Required exclusions” are included when reporting the “Number of required exclusions” data element.

HEDIS 2019

10.15.2018 Plan All-Cause Readmissions Organizations are instructed to use the file run date to determine the member’s SES stratification in the last 3 months of the continuous enrollment period. For the PCR measure, the continuous enrollment period is 365 days prior to the Index Discharge Date through 30 days after that date. How is a member’s SES stratification determined if the run date falls after the end of the continuous enrollment period?

When determining the SES stratification for PCR, use the last month of the continuous enrollment period, regardless of the run date. For example, if the continuous enrollment period ends July 1, use May, June and July to assess the member’s SES stratification, regardless of the run date of the July Monthly Membership Detail Data File.

HEDIS 2019

10.15.2018 Rules for Allowable Adjustments The General Guidelines in the Rules for Allowable Adjustments states, “use the separate HEDIS Adjustments VSD to calculate measure rates stemming from adjusted measure specification.” Does this mean that ONLY the HEDIS Adjustments VSD must be used?

No. The Allowable Adjustments VSD does not contain the standard HEDIS value sets; standard HEDIS value sets are in the HEDIS 2019 Volume 2 VSD. The Allowable Adjustments VSD includes only SNOMED and LOINC codes that are not in the Volume 2 VSD. Organizations collecting data using the rules for allowable adjustments can elect (but are not required) to use the value sets in the Allowable Adjustments VSD.

HEDIS 2019

10.15.2018 Follow-Up After ED visit for People With Multiple High-Risk Chronic Conditions In Step 2 (Exclusions), ED visits followed by admission to an inpatient care setting on the date of the visit or within 7 days after the visit are excluded. Should ED visits that result in an inpatient stay (when the ED date of service occurs any time during the admission [admission date through discharge date]) also be excluded?

Yes. Exclude ED visits that result in an inpatient stay.

HEDIS 2019

10.15.2018 Use of Imaging Studies for Low Back Pain Should the “Numerator events by supplemental data” row be removed from the Data Elements Table in the Use of Imaging Studies for Low Back Pain (LBP) measure?

Yes. Remove the “Numerator events by supplemental data” row in the Data Elements Table.

Exchange 2019

10.15.2018 Total Membership How should organizations handle dually enrolled members for the Total Membership (TLM) measure? Should organizations follow the "total unduplicated membership" rule, or should they follow General Guideline 15 and count the member twice (where applicable)?

Organizations should refer to General Guideline 15 in the HEDIS 2019 Volume 2 publication for guidance on reporting members with dual enrollment for the TLM measure. However, when General Guideline 15 allows members to be included in more than one product line deduplicate and count members only once in the measure as follows:

 -Report members with dual Medicaid/Medicare enrollment in the Medicare product line.       

 –For other dual enrolled members report the members in the primary product line.

HEDIS 2019

10.15.2018 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis Should the “Numerator events by supplemental data” row be removed from the Data Elements Table in the Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB) measure?

Yes. Remove the “Numerator events by supplemental data” row in the Data Elements Table.

Exchange 2019