FAQ Directory

For the 2016 standards year, NCQA evaluates and scores the UM 4, Element H file review as normal during the onsite survey.
The final score will be adjusted, after the onsite survey, to 100% if the organization includes all denials required by UM 4, Element H in the file review universe. 
If the organization does not include all denials in the file review universe, NCQA will adjust the organization's final score to 50% for the 2016 standards year and 0% thereafter.
 

UM-CR 2016

As stated in the measure guidance section for the DMS and DRR measures, include encounters where a diagnosis of major depression or dysthymia was addressed. The intent is to use encounters that are associated with managing depression to identify members in the Initial Population and to identify encounters to be included in the denominator calculation for Rate 2. In the HEDIS 2017 October Update, the Depression Encounter Value Set was renamed Interactive Outpatient Encounter Value Set, to clarify that it identifies outpatient encounters that can take place in a variety of settings. These encounters must be associated with a diagnosis of major depression or dysthymia in order to meet the intent of the measures.

HEDIS 2017

No.  Use February 28 of the measurement year when identifying the Age of the member for Rate 1 and Rate 2.  NCQA does not make changes that impact software programming after the release of the Technical Update memo.

HEDIS 2017

Yes. Organizations may make this change to the CDC measure. On page 143, in step 1 of the Medical Record, organizations may delete the second and third bullets and add the following bullet:

• Taken on the same day as a diagnostic test or procedure that requires a change in diet or medication regimen on or one day before the day of the test or procedure, with the exception of fasting blood tests.

NCQA allows organizations to make this change because it does not impact software programming for the measure.  If an organization makes this change, it must do so consistently across all members.

HEDIS 2017

The updated Value Set Directory (VSD) is available to customers who purchased HEDIS 2017 Volume 2. Go to the NCQA Download Center to obtain the file: https://downloads.ncqa.org/customer/Login.aspx.
Note: The updated VSD is not labeled “10-3” in the Download Center. Click “Download” and the file name will include the date 10.03.16.

HEDIS 2017

The following types of denials are included in file review for UM 4, Element H (UM 4F in UM-CR and MBHO):

• Denials based on benefits that underwent a medical necessity review, which determined there was a benefit exclusion.
• Denials based on failure to follow the organization’s reasonable filing procedures. (i.e., lack of timely filing, lack of prior authorization).
• Auto-adjudicated claims denials or point of service (POS) claim denials that were not based on medical necessity (excluding duplicate claims).
• Denials not listed above that are not based on medical necessity, such as reversals or prior decisions due to fraud or improper billing.

UM-CR 2016

No. Facilities may not be mapped to a provider type unless an organization can demonstrate that all providers rendering services at the facility meet the NCQA provider definition defined in Appendix 3. Organizations should work with their HEDIS Compliance Auditor, who can review and approve mapping.

HEDIS 2017

No. To be considered a direct transfer, the admission date for the second stay must be on the same date of service or one day after the discharge date from the first stay.

HEDIS 2017

No. The inpatient stay must be on the same date of service or one day after the ED or observation visit date.

HEDIS 2017

No. A third paragraph should have been added that reads, “For factor 2, NCQA reviews a documented process, reports or materials, depending on the action taken to address identified opportunities.”
 
The update was intended to give organizations the option of presenting its updated policies and procedures, materials or a report showing revisions, if the intervention was revision of policies and procedures or materials.
 
NCQA will correct the scope of review for both elements in the November release of the NCQA Corrections, Clarifications and Policy Changes to the 2016 HP Standards.
 
 

Health plans that delegate the following structural requirements to an NCQA-Accredited MBHO are eligible to receive automatic credit, as stated in Appendix 5, Table 3 (this is Appendix 3, Table 2¹ in the MBHO standards and guidelines), if they meet the criteria for automatic credit. The organization does not need to provide its own documentation.

• QI 1, Element A: Program Structure, factor 2 (MBHO QI 1, Element A, factor 3).
• QI 4, Element B: Behavioral Healthcare Telephone Access Standards (MBHO QI 5, Element B).
• NET 1, Element D: Practitioners Providing Behavioral Healthcare, factors 1–3 (MBHO QI 4, Element B, factors 1–3).
• NET 2, Element B: Access to Behavioral Healthcare, factors 1–3 (MBHO QI 5, Element A, factors 1 and 2).
• UM 1, Element A: Utilization Management Structure, factors 2 and 4 (MBHO UM 1, Element A, factors 1 and 2).
• UM 1, Element C: Behavioral Healthcare Practitioner Involvement (UM 1, Elements A and B).

 
¹MBHO equivalent standard/element is in parentheses.

Organizations that delegate the following structural requirements to an NCQA-Accredited health plan are eligible to receive automatic credit, as stated in Appendix 5, Table 2, if they meet the criteria for automatic credit. The organization does not need to provide its own documentation.

·    QI 4, Element B: Behavioral Healthcare Telephone Access Standards.

·    QI 5, Element F: Case Management Process.

·    NET 1, Element B: Practitioners Providing Primary Care, factors 1 and 2.

·    NET 1, Element C: Practitioners Providing Specialty Care, factors 1–4.

·    NET 1, Element D: Practitioners Providing Behavioral Healthcare, factors 1–3.

·    NET 2, Element A: Access to Primary Care. 

·    NET 2, Element B: Access to Behavioral Healthcare.