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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11.15.2017 Supplemental Data Is it acceptable to flag records in a supplemental data file as paid or denied when there is no payment attached to the records in the file?

No. It is not acceptable to classify a supplemental data source as paid or denied unless it is known whether the data in the data source were paid or denied. This is especially true when the data are being used for measures that require claims payment statuses (e.g. LBP, NCS). Organizations should not assume services were denied services just because there isn't a payment status associated with them. For measures where payment status is required, the auditor must be able to validate that the payment status is accurate.

HEDIS 2018

11.15.2017 Reporting Requirements The HEDIS 2018 Volume 2 Technical Update memo announced the retirement of “Annual Monitoring for Patients on Persistent Medications (MPM)” for Medicare and the name change from “Inpatient Hospital Utilization (IHU)” to “Acute Hospital Utilization (AHU).” This caused a discrepancy between the CMS Reporting Memo and HEDIS 2018 Volume 2 Technical Specifications. Will CMS release a clarification on what must be reported for HEDIS 2018 for Medicare?

Yes. CMS released a clarification on October 11, 2017, through HPMS, announcing that MPM was retired and is not required for HEDIS 2018 reporting; it also clarified that “Inpatient Hospital Utilization” is now “Acute Hospital Utilization” and should be reported as the updated measure. If you have additional questions, contact CMS at HEDISquestions@cms.hhs.gov.

HEDIS 2018

11.15.2017 Use of Opioids at High Dosage In the HEDIS 2018 Volume 2 Technical Update memo Table UOD-A includes a variable ranging from 4-12 for the MED Conversion Factor for methadone based on mg/day of methadone used. However, in the HEDIS 2018 NDC MLD Directory all NDCs for Methadone under the medication list "Opioid Medication" have a MED Conversion Factor (column M) of 3. For performing the MED calculation in UOD, which MED Conversion Factor should be used for methadone?

For HEDIS 2018 reporting, for methadone, the MED conversion factor of "3" should be used as listed in the NDC list; not the factors listed in Table UOD-A. We will reevaluate using the sliding scale conversion factors for HEDIS 2019.

HEDIS 2018

11.15.2017 General Guidelines General Guideline 17 says that "Members with dual commercial and Medicaid coverage must be reported in the commercial HEDIS reports. These members may be excluded from the Medicaid HEDIS reports." If a member has primary insurance in a Medicaid plan and secondary insurance in another Medicaid plan at any time during the measurement year, should the secondary Medicaid plan report the member in their HEDIS report?

To meet criteria for dual coverage, the member should have dual coverage at the end of the continuous enrollment period (dual coverage is assessed on a measure-by-measure basis). For example, if a measure's continuous enrollment period ends on December 31 of the MY and has dual Medicaid and commercial enrollment on that date, then the member may be excluded from the Medicaid HEDIS reports for the measure and only be reported in the commercial product line (General Guideline 23 in HEDIS 2018 Volume 2). In cases where the member is dually enrolled in two Medicaid plans, the secondary Medicaid payer would have the choice to exclude the member if the primary Medicaid coverage was offered through a different organization.

HEDIS 2018

11.15.2017 DEA or CDS Certificates Is a photocopy of a practitioner's DEA certificate acceptable documentation for CR 3, Element A, factor 2?

Yes. Although photocopies are generally not acceptable documentation for verifying credentialing information, they are accepted for DEA certification because the DEA does not provide phone or written verification.

HP 2018

11.15.2017 The Value-based Payment worksheet What is the Value-Based Payment worksheet for PHM 3B, and where can we find it?

The Value-Based Payment worksheet gives instructions on required reporting to satisfy element PHM 3B: Value-Based Payment Arrangements. It is a workbook that must be completed as part of the survey tool.

HP 2018

11.15.2017 Delegation of NET Directories How is NET 7, Element E, factor 1 scored when an organization delegates only the directory functions in NET 6?

The organization is scored NA for factor 1 because the physician and hospital directories do not involve network management procedures.
 

HP 2018

11.15.2017 Updated: Timeliness of postservice appeal decisions for Medicare and Medicaid Does the recent change for Medicare and Medicaid postservice appeals from 60 calendar days to 30 calendar days align with Chapter 13 of the Medicare Managed Care Manual?

No. Medicare product lines continue to follow the 60-calendar-day time frame for postservice appeals.

Note: The requirement is correct for Medicare product lines; Medicaid product lines continue to follow the 30-calendar-day time frame for postservice appeals.

HP 2018

11.09.2017 Additional Resources Are there any outside resources that may help me in the PCMH transformation process?

Content Area Criteria Resource Link Description
TC 02 http://www.ihi.org/resources/Pages/Changes/OptimizetheCareTeam.aspx Resource on how to optimize staff responsibilities
  02 https://www.integration.samhsa.gov/operations-administration/OATI_Tool3_ART.pdf Toolkit on how to optimize administrative staff responsibilities to benefit clinical practice
  02 http://www.improvingprimarycare.org/team/pcp Resource on how to optimize staff responsibilities
  04 https://www.stepsforward.org/modules/pfac Module teaching how to create a patient advisory council
  07 http://www.nachc.org/research-and-data/prapare/toolkit/ Toolkit to better understand social determinants of health
  08 https://integrationacademy.ahrq.gov/sites/default/files/AHRQ_AcademyGuidebook.pdf Information on behavioral healthcare integration in primary practice
KM 02 G https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/ Social needs screening toolkit
  12 https://www.cdc.gov/media/releases/2012/p0614_preventive_health.html Discussion on benefits of preventative care
  14 https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/match/match.pdf Guide to medication reconciliation at transitions
  16 http://www.teachbacktraining.org/ Information on teach back training
  17 http://www.improvingprimarycare.org/work/medication-management Guide to medication management
  24 https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html Toolkit for shared decision making
  24 http://msdmc.org/3-assess/ Toolkit for shared decision making
  24 https://shareddecisions.mayoclinic.org/ Informative website about shared decision making
  13 http://www.jabfm.org/content/28/2/170.full.pdf   "Patient Empanelment: The Importance of Understanding Who Is at Home in a Medical Home"
AC 13 http://www.annfammed.org/content/10/5/396.full  "Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation"
    http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/aug/1764_hong_caring_for_high_need_high_cost_patients_ccm_ib.pdf Article discussing benefits and strategies to care management
CM 03 https://nf.aafp.org/Shop/practice-transformation/risk-stratified-care-mgmt-rubric Risk stratification rubric available to members of the AAFP
  03 http://www.calquality.org/storage/documents/cqc_complexcaremanagement_toolkit_final.pdf Risk stratification rubric from California Quality Collaborative
  03 http://www.millimanriskadjustment.com/ MARA  – The Milliman Advanced Risk Adjuster is a model of risk stratification in which risk scores are normalized to a given population.
  04 http://www.aafp.org/fpm/2015/0100/fpm20150100p7-rt1.pdf Care Plan template from AAFP, not exclusive to members
  06 http://www.dartmouthatlas.org/downloads/reports/preference_sensitive.pdf Resource on how to incorporate patient preference into care management
  08 http://www.ihi.org/resources/pages/tools/selfmanagementtoolkitforclinicians.aspx Toolkit to aid clinicians in promoting self-management
  08 https://www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/index.html Resources on self management
  08 http://champsonline.org/tools-products/clinical-resources/patient-education-tools/patient-self-management-tools Condition specific self management tools
  08 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/ Article discussing proper communication between primary and specialist clinicians
CC 14 http://nihcr.org/analysis/improving-care-delivery/prevention-improving-health/ed-coordination/ Information on improving communication between emergency and primary physicians
  16 https://share.kaiserpermanente.org/article/kaiser-permanente-study-finds-tailored-post-hospital-visits-lower-risk-readmission-medicare-advantage-patients/ Article discussing advantages of post hospital primary care visits
QI   https://www.ahrq.gov/sites/default/files/publications/files/pcmhqi2.pdf Resource for building quality improvement in primary care
  03 http://www.ihi.org/resources/Pages/Measures/ThirdNextAvailableAppointment.aspx Information on how to utlize third next available appointment measurement
  08 https://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod4.html Benefits of PDSA cycle

PCMH 2017

10.15.2017 ECDS What does NCQA mean by “information has to be accessible by the health care team at the point of care”?

To qualify for HEDIS ECDS reporting, practitioners and practitioner groups that are accountable for clinical services provided to members must have access to data used by plans for quality measure reporting, regardless of the SSoR.

NCQA does not currently specify a method of data access, but a core principle of ECDS reporting is that the information needed to deliver the highest-quality care must be available to the entire health care team responsible for managing a member’s health.

Qualifying modes of access may be as simple as a provider’s phone request for member information, or as sophisticated as an integrated decision support system. The care team’s ability to access data must be documented, to provide evidence that information is available whether or not it is accessed.

HEDIS 2018

10.15.2017 ECDS What is the IP-ECDS Coverage Rate threshold for public reporting of ECDS measure results?

Organizations do not report an IP-ECDS coverage rate; they report a count of members in the initial population covered by ECDS. NCQA does not publicly report these data, which are for internal NCQA use and for benchmarking analysis to help determine the timeline for public reporting.

HEDIS 2018

10.15.2017 Use of Opioids at High Dosage and Use of Opioids From Multiple Providers Step 2 of the UOD and UOP eligible population states to exclude “members who had only a single opioid medication (Opioid Medications List) dispensing event.” Does a member who had multiple prescriptions (for the same or different medications) on the same date of service (with no prescriptions on other dates of service during the measurement year) meet criteria for exclusion?

Yes. The intent is to exclude members who were dispensed opioids on only one date of service during the measurement year. If the member had multiple prescriptions (for the same or different medication) on one date of service and had no opioid prescriptions on another date of service during the measurement year, the member is excluded.

HEDIS 2018