Yes. If medical records document that the member meets exclusion criteria, the member is excluded from the sample and replaced with a member of the oversample.
HEDIS 2023
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.
The KED measure provides actionable information for chronic kidney disease identification and management. General guidance from our experts is that tests included in the measure should align with guideline recommendations from the American Diabetes Association and the National Kidney Foundation. For this reason, only quantitative uACR tests are allowed and semi-quantitative tests are not considered measure compliant. Removing LOINC code 32294-1 from the value set maintains these coding parameters.
HEDIS 2024
No. Members with documentation of “hysterectomy” and documentation indicating that they no longer need Pap testing/cervical cancer screening must remain in the measure for MY 2023 reporting. Members with documentation of a “vaginal pap smear” and documentation of “hysterectomy” must also remain in the measure for HEDIS MY 2023 reporting. This is because the documentation must match the clinical specificity of the codes in the value sets and there are no codes that are clinically synonymous with these examples.
There must be evidence of a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix in order to meet required exclusion criteria for MY 2023 reporting.
Documented “vaginal hysterectomy” or “complete/total/radical hysterectomy” that matches a definition in applicable value sets may be used to meet criteria, subject to auditor approval.
HEDIS 2023
No. Only addressing the UM denial notification to the provider does not meet the intent of the requirement. The UM denial notification must also be addressed to the attending/treating practitioner.
If information on the attending/treating practitioner was not provided with the request, the organization attempts to identify the practitioner and documents its efforts to identify the practitioner. If the organization is not able to obtain the name of the attending/treating practitioner, the practitioner’s name is not required. In such a case, the organization must address the notification "To the Attention of the Attending/Treating Practitioner.”
For urgent concurrent decisions, the organization may inform the hospital Utilization Review department staff without attempting to identify the attending/treating practitioner, with the understanding that staff will inform the practitioner.
In all cases, if the practitioner is not known, the organization must address the notification “To the Attention of the Attending/Treating Practitioner”; the practitioner’s name is not required.
MBHO 2023
No. Only addressing the UM denial notification to the provider does not meet the intent of the requirement. The UM denial notification must also be addressed to the attending/treating practitioner.
If information on the attending/treating practitioner was not provided with the request, the organization attempts to identify the practitioner and documents its efforts to identify the practitioner. If the organization is not able to obtain the name of the attending/treating practitioner, the practitioner’s name is not required. In such a case, the organization must address the notification "To the Attention of the Attending/Treating Practitioner.”
For urgent concurrent decisions, the organization may inform the hospital Utilization Review department staff without attempting to identify the attending/treating practitioner, with the understanding that staff will inform the practitioner.
In all cases, if the practitioner is not known, the organization must address the notification “To the Attention of the Attending/Treating Practitioner”; the practitioner’s name is not required.
UM-CR-PN 2023
Yes. Organizations may use an API to access data from a primary or approved source, and must provide documentation that the API collects information only from primary or approved sources.
Organizations that use an API must still meet the “Appropriate documentation” requirements in CVO 1, Element A, including documentation that the organization's staff reviewed the information.
As noted in an FAQ from February 15, 2023, use of another entity’s software to collect credentialing information is not considered delegation unless the entity also reviews the information on the organization’s behalf.
CVO 2024
Yes. Organizations may use an API to access data from a primary or approved source, and must provide documentation that the API collects information only from primary or approved sources.
Organizations that use an API must still meet the “Appropriate documentation” requirements in CR 1, Element A, including documentation that the organization's staff reviewed the information.
As noted in an FAQ from February 15, 2023, use of another entity’s software to collect credentialing information is not considered delegation unless the entity also reviews the information on the organization’s behalf.
UM-CR-PN 2023
Topic | Update Highlights |
Front Matter (Audit Section) | Evidence of implementation submitted for an audit, including reporting data, must be recent to the time of the audit. |
Front Matter | Added a section addressing conflicts with regulatory requirements. This applies to all Recognition products. |
CM 04 | Added: “The care plan needs to be written in a health literacy level accessible to the patient (not medical jargon or billing codes).” Also added – “Note: After-visit summaries may only be used if it contains plain language and shows patient involvement in the creation of the plan.” |
KM 06 | Removed “pronouns” and added “language” in the guidance section as examples that may not be submitted for “other aspects of health”. |
KM 09 | Added clarification on evidence: “Practices are to submit a report that is broken down by numerator/denominator and percentages for each category. For example, Black or African American = 400/1000 (40%); Asian = 300/1000 (30%), etc.” |
PM 20 | New criterion – Person-Driven Outcomes Approach: Monitoring and Follow-Up |
PCSP 2019
Topic | Update Highlights |
Front Matter (Audit Section) | Added “Evidence of implementation submitted for an audit, including reporting data, must be recent to the time of the audit.” |
Front Matter | Added a section addressing conflicts with regulatory requirements. This applies to all Recognition products. |
CM 04 | Added: “Note: After-visit summaries may only be used if they contain plain language and show patient involvement in the plan’s creation.” Also added, “The care plan is written at a health literacy level accessible to the patient (i.e., does not contain medical jargon, abbreviations/acronyms or billing codes).” |
KM 09 | Removed “pronouns” and “language” in the guidance section as an example of “other aspects of health”. |
KM 09 | Added a clarification about evidence, “Practices are to submit a report that is broken down by numerator/denominator and percentages for each category. For example, Black or African American = 400/1000 (40%); Asian = 300/1000 (30%), etc." |
AC 01 | Added to the guidance: The key to this criterion is patient preference. Some examples of questions asked may include, but are not limited to: • Our practice is considering extended hours to 7PM. What day of the week would you most prefer? • Our practice offers same day appointments at 9AM each day. Does this time work for your same day needs? Yes/No with a follow-up question: If not, please identify a time that you prefer. • If scheduled telehealth visits were offered, would you use them instead of an in-person office visit? (Y/N or Likert Scale). Can follow-up with options. |
CM 11 | New criterion – Person-Driven Outcomes Approach: Monitoring and Follow-Up |
QI 01 and 02 | Clarified that beginning in 2024, standardized measures must be used and reporting through the Measures Reporting Tile in Q-PASS. |
PCMH 2017
Yes, if the delegation agreement addresses the required information in the Explanation. The delegation agreement must specify:
WHP 2019