FAQ Directory

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.

This applies to the following Programs and Years:

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.

• 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.

This applies to the following Programs and Years:

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.
 

This applies to the following Programs and Years:

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)  

This applies to the following Programs and Years:

Yes, if the interaction meets criteria based on the measure specifications. The caregiver is not required to be designated as the patient’s legal guardian for the interaction to count toward the measure.  

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

No. For PCR, MMP members are removed from Medicaid reporting and are included in only Medicare reporting.

This applies to the following Programs and Years:

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).

This applies to the following Programs and Years:

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

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years: