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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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
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
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
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).
HP 2019
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
