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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3.15.2019 LTSS 4, Element C: Analysis of Unplanned transitions The explanation for LTSS 4, Element C, factor 1 states that analysis includes patterns of unplanned admissions, readmissions, emergency room visits and repeat visits, and admission to participating and nonparticipating facilities.
Is the organization required to include all these areas to meet the intent of the factor?

No. The organization is not required to include all these areas in its analysis, but at a minimum, must evaluate rates of unplanned admissions to facilities and emergency room visits to identify areas for improvement.

This applies to the following Programs and Years:
CM 2017|CM-LTSS 2017|HP 2019|MBHO 2019

3.15.2019 PHM 5, Element F: Aligning the examples with the factor explanation Are the examples in PHM 5, Element F all-inclusive? Does using only the listed questions meet the requirement?

No. As a general rule, examples should be used as a guide. Examples of questions for PHM 5, Element F that are not prescriptive, but address each requirement listed in the Explanation, include:

1.  How satisfied are you with the information provided about the overall case management program?

2.  How would you rate your experience with the case manager overall? With the program staff?

3.  Did the case manager and other program staff treat you with courtesy and respect?

4. Was the information provided to you useful?

5. How well were you able to follow the recommendations provided to you by the case manager?

6. Were you able to achieve your health goals in your case management plan?

This applies to the following Programs and Years:
HP 2019

3.15.2019 UM 8, Element A MAXIMUS What factors are scored “Met” for UM 8, Element A if an upheld denial was sent to MAXIMUS?

Factors 7-13 should be scored as “Met” for upheld denials sent to MAXIMUS.

This applies to the following Programs and Years:
HP 2018|MBHO 2018|UM-CR-PN 2018

3.15.2019 Citing a benefit provision If a benefit provision is used as the basis for the denial, how must it be cited in the notification?

Referencing benefit documents such as the member handbook or Certificate of Coverage by title alone is not specific enough to meet the requirement. Because benefit documents are often large and complex, the organization must direct members to the specific location of the information, either by section title or page number.

The reference must still support the organization’s decision and relate to the reason for the request

This applies to the following Programs and Years:
HP 2018, 2019|MBHO 2018, 2019|UM-CR-PN 2018, 2019

3.12.2019 PCMH Criteria and HIEs Can utilization of a Health Information Exchange (HIE) meet PCMH criteria?

Participating in an HIE can help practices demonstrate PCMH criteria; however, connection alone does not demonstrate the evidence needed to meet the following criteria. Practices must demonstrate how they use the HIE to meet each criterion. Utilization of an HIE could help meet the following criteria:
 

PCMH Criteria 

NYS PCMH  
Required Criteria 

AC 12(2 Credits) 

Continuity of Medical Record Information 

✔ 

CM 09(1 Credit) 

Care Plan Integration 

✔ 

CC 15(Core) 

Sharing Clinical information  

 

CC 17(1 Credit) 

Acute Care After-Hours Communication 

 

CC 18(1 Credit) 

Information Exchange During Hospitalization 

 

CC 19(1 Credit) 

Patient Discharge Summaries 

✔ 

CC 21(Maximum 3 Credits) 

External Electronic Exchange of Information 

✔  
(A is required) 

This applies to the following Programs and Years:
PCMH 2017

2.15.2019 Plan All-Cause Readmissions (PCR) The “Total” data elements for Medicare in Table PCR-A must match the “Total Medicare” data elements in Table PCR-B. Are organizations required to report the totals in both tables?

No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-A. Remove the “Total Medicare” row from Table PCR-B that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-A. The asterisked language may also be removed under these two tables.

This applies to the following Programs and Years:
HEDIS 2019

2.15.2019 Plan All-Cause Readmissions (PCR) The “Total” data elements for Medicare in Table PCR-C must match the “Total Medicare” data elements in Table PCR-D. Are organizations required to report the totals in both tables?

No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-C. Remove the “Total Medicare” row from Table PCR-D that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-C. The asterisked language may also be removed under these two tables.

This applies to the following Programs and Years:
HEDIS 2019

2.15.2019 Language in denial letters May an organization send a single denial letter to a member and a practitioner that contains the reason for the denial in both layman terms (for the member) and clinical terms (for the practitioner)?

Yes. The organization may send a single letter to the member and practitioner that includes the specific reason for the denial, in language that would be easily understood by the member. The letter may also include, in a separate section, additional clinical or technical language directed toward a practitioner.

When NCQA reviews the letter to ascertain if the reason for the denial would be easy for the member to understand, it considers both the written reason and the context of the language and whether the information can be understood in context.
 

This applies to the following Programs and Years:
HP 2018, 2019|MBHO 2018, 2019|UM-CR-PN 2018, 2019

2.15.2019 Supplemental Data When pharmacy data are classified as supplemental data, the following data elements must be present: the generic name (or brand name), strength/dose, route and date when the medication was dispensed to the member. If all the required data elements are included except the dispense date, can a start date be used instead?

No. When pharmacy data are used as supplemental data, a dispense date is required; a start date may not be used as a proxy. There are no exceptions to the requirements for pharmacy data, as described in General Guideline 30.

This applies to the following Programs and Years:
HEDIS 2019

1.24.2019 KM 02G Resource

1.15.2019 Supplemental Data When using supplemental data for measures that require a result, does the actual numeric result need to be present in the supplemental data to meet criteria?

Yes. For all measures that require a result, the actual numeric value of the result must be present in the supplemental data to meet criteria. For example, when reporting the BP control indicator of the CDC measure, documentation of the code 3078F alone in the supplemental data cannot be used to indicate a diastolic level that is less than 80. The actual diastolic value (e.g., 79) must be present in the supplemental data to meet criteria. It is appropriate for the approved data to be mapped to code 3078F (or applicable codes) to integrate into vendor or internal systems for measure calculation. Mapping would need to be reviewed and approved by the auditor.

The only exceptions to this are described in a General Guideline FAQ posted 11/15/2018. The exceptions described in the 11/15 FAQ are for the ABA and WCC measures. When reporting the BMI indicators for both measures, height and weight do not need to be in the supplemental data, but the actual BMI value or BMI percentile, with the date, must be present. For the counseling for physical activity indicator of the WCC measure, a code in the supplemental data that is dated during the measurement year alone meets criteria. For counseling for nutrition indicator of the WCC measure, a code in the supplemental data that is dated during the measurement year alone meets criteria.

This applies to the following Programs and Years:
HEDIS 2019

1.15.2019 Death as an Exclusion in HEDIS Is death a valid exclusion for HEDIS measures?

NCQA expects plans to disenroll deceased members. Members who died during the continuous enrollment period would not meet the measure’s eligible population criteria (e.g., continuous enrollment and anchor date requirements) and would not be included in the measure denominator. However, a member who meets the continuous enrollment criteria remains in the measure. For example, when reporting the MRP measure, a member who was discharged on July 1 and died on August 1, but enrollment data indicates the member is enrolled in the organization during the continuous enrollment period (the date of discharge through 30 days after discharge) must remain in the measure.

Keep in mind that organizations may not use other data sources (e.g., medical record data) when removing deceased members.
 

This applies to the following Programs and Years:
HEDIS 2019