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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1.15.2018 Transitions of Care The criteria for TRC Notification of Inpatient Admission states that notification should occur on the day of admission or the following day. However, one bullet states that evidence of tests ordered by the PCP during the inpatient stay is valid, as well. If a member stays in the hospital for 10 days, and there is no evidence of the PCP ordering tests until day 4 of the stay, it is this compliant for the indicator?

No. To be compliant for the indicator, documentation that the PCP/care provider ordered tests/ treatment to occur during the inpatient stay must be documented on the day of admission or on the following day. Documentation on day 4 does not count.

This applies to the following Programs and Years:
HEDIS 2018

1.15.2018 Prenatal and Postpartum Care Is the ability to choose EDD or date of delivery based on the member level or on the organization level?

The determination whether to use EDD or date of delivery is made at the member level. Flexibility is allowed because in the case of pre- or post-term deliveries, the delivery date may not be the most accurate date for determining the first trimester.

This applies to the following Programs and Years:
HEDIS 2018

1.12.2018 ACO- Diabetes Care: HbA1c Testing The ACO clinical data file layout released on 1/12/17 includes the CDC: HbA1c Testing measure (one test). This is different from what is collected for Value Based P4P, is this correct?

Yes. Although the other ACO measures and specifications align with the VBP4P measures, VBP4P committees approved the addition of the CDC: HbA1c testing measure in the ACO measure set as a single test instead of two tests in alignment with IHA’s Cost Atlas, and because VBP4P will retire the Two HbA1c tests measure in MY 2018.

This applies to the following Programs and Years:
IHA P4P

1.12.2018 VBP4P- VBP4P Exclusions: Members Impacted by CA Wildfires Is IHA making exceptions for VBP4P reporting for areas affected by the wildfires in California? Will IHA allow an exclusion for members affected by these wildfires?

The VBP4P Governance Committee has approved a program wide optional exclusion for members living in the following zip codes only: 95403, 95404, 95405, 95409.

POs have the option to exclude these members from MY 2017 VBP4P reporting. This exclusion is “all or none”: All members living in these zip codes must be excluded for all measures, regardless of numerator status, if the exclusion is exercised.

This applies to the following Programs and Years:
IHA P4P

1.12.2018 MA- Medicare Advantage Plans Sharp Health Plan is included in the MY 2017 VBP4P clinical data file layouts posted on iha.org, but was not included in the final MY 2017 VBP4P Manual as a Medicare Advantage participating plan. Is Sharp Health Plan reporting for MA in MY 2017?

Yes. Sharp Health Plan confirmed its participation in Medicare Advantage reporting after the final MY 2017 VBP4P was published on December 1, 2017. The final PO Master will reflect its Medicare Advantage contracts for reporting.

This applies to the following Programs and Years:
IHA P4P

12.15.2017 Unhealthy Alcohol Use Screening and Follow-Up In the HEDIS 2018 Volume 2 Technical Update memo, the updated measure specification for Unhealthy Alcohol Use Screening and Follow-Up (ASF) now indicates there are three strata, but the specifications still note there are four. Which is correct?

There are three strata. The text should be revised in the following two places:

  • Page 43, under “Single-Question (Positive) Response,” bullet 1 should reference “Males (Male AdministrativeGender Value Set) in Strata 1–2”; bullet 3 should reference “All members in Stratum 3.”
  • Page 44, “Single-Question (Negative) Response,” bullet 1 should reference “Males (Male AdministrativeGender Value Set) in Strata 1–2 and bullet 3 should reference “All adults in Stratum 3.”

This applies to the following Programs and Years:
HEDIS 2018

12.15.2017 Reporting Requirements Last year, NCQA added the IS 3.1 standard in the Roadmap, stipulating that if a facility is mapped to a provider type, all providers at the facility must be of that provider type. Clarify this standard and whether a majority-mapping should be allowed this year. If so, at what level should it be enforced? Should a percentage of providers on the facility roster be of the mapped type, or is it preferable to review for whether a certain percentage of sampled services on claims be those typically received with the provider type? Should all mapped facilities be investigated individually, or is it acceptable to review the two or three with the highest volume?

For HEDIS reporting, NCQA does not allow blanket mapping a facility to a provider type, unless all providers who render services at the facility meet requirements for the provider type.

For HEDIS measures with a provider-type requirement, the information must be present for the service to be counted. For a facility to be mapped to a PCP (or another provider type) the organization must provide evidence that everyone at the facility meets the provider type requirement.

NCQA does not have an acceptable threshold allowance for auditors to audit against. Each facility must be reviewed individually. The auditor determines the impact of each facility's data on measures that require a particular provider type. From there, the auditor must review, with a level of certainty, who practices at the facility, the services they are contracted to perform and the potential impact to measures if an unacceptable provider renders a service that might count for a measure.

This applies to the following Programs and Years:
HEDIS 2018

12.15.2017 Transitions of Care The HEDIS 2018 Volume 2 Technical Update states that documenting preadmission exams and communicating planned admissions are not limited to the time frame criteria as other evidence for the Notification of Inpatient Admission indicator. Are there time frames that must be met?

No. There are no additional time frame requirements for preadmission exams or communicating about planned admissions, other than what is documented in the measure specifications. For example, it may meet the standard time frame (on the day of admission or the following day) or it may occur earlier. To prevent information from "different discharges" from being counted, the measure requires that it "must clearly pertain to the denominator event."

This applies to the following Programs and Years:
HEDIS 2018

12.15.2017 Controlling High Blood Pressure When confirming a hypertension diagnosis, a code from the Essential Hypertension Value Set can be used. This value set includes only ICD-10 codes. May ICD-9 codes be used to confirm the diagnosis?

Yes. Organizations may look back any time during a member’s history to confirm the diagnosis (including when ICD-9 codes were in use). Documentation of ICD-9 diagnosis codes 401.0, 401.1 or 401.9 may also confirm a diagnosis of hypertension.

This applies to the following Programs and Years:
HEDIS 2018

11.15.2017 Transitions of Care The HEDIS 2018 Volume 2 Technical Update memo indicates the following change in the Transitions of Care specifications: In the first sentence of the third paragraph, replace “date/time” with “date.”
Should this change also apply to the first bullet in the “Note” section of the technical specifications that reads, “The following notations or examples of documentation do not count as numerator compliant:
*Documentation of notification that does not include a time frame or date/time stamp.”

Yes. Replace the reference to “date/time” in the first bullet in the Note section with “date.”

This applies to the following Programs and Years:
HEDIS 2018

11.15.2017 Hospitalization for Potentially Preventable Complications On Page 37 of the HEDIS 2018 Volume 2 Technical Update memo, the “Number of Chronic ACSC Non-Outliers and Acute ACSC Non-Outliers” and “Number of Chronic ACSC Outliers and Acute ACSC Outliers” reporting categories have the same description.
Should the first reporting category listed above state ‘non-outlier’ instead of ‘outlier’?

Yes; the specifications should read “Reporting: Number of Chronic ACSC Non-Outliers and Acute ACSC Non-Outliers:The number of chronic ACSC non-outlier members and the number of acute ACSC non-outliers for each age and gender group and the overall total.”

This applies to the following Programs and Years:
HEDIS 2018

11.15.2017 Weeks of Pregnancy at Time of Enrollment The HEDIS 2018 Volume 2 Technical Update memo includes a RAND number for the “Weeks of Pregnancy at Time of Enrollment” measure. Is this correct?

No. “Weeks of Pregnancy at Time of Enrollment (WOP)” was retired in HEDIS 2017; the RAND number was inadvertently included in the HEDIS 2018 Volume 2 Technical Update memo.

This applies to the following Programs and Years:
HEDIS 2018