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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11.09.2017 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

This applies to the following Programs and Years:
PCMH 2017

10.15.2017 Children With Chronic Conditions When assessing Prescreen Status Code criteria, does the visit code and diagnosis code have to be on the same claim?

Yes; because the Prescreen Status Code criteria requires a code to be in conjunction with another code, the codes must be on the same claim (claims on the same date of service cannot be combined to meet criteria).

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 ECDS How are ECDS different from supplemental data?

The ECDS reporting method uses much of the same data classified as supplemental for other HEDIS measures, but ECDS measures adhere to different reporting rules from those in other HEDIS domains. Unlike supplemental data used for HEDIS, data for ECDS reporting are classified by source and are used to report all measure elements (e.g., denominator, exclusions, numerator).

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 ECDS Must the eMeasure section in the Roadmap be completed for ECDS measures?

Plans work with their NCQA-Certified auditor to complete the most appropriate section of the Roadmap for the data source. The eMeasure section is intended for use by data aggregators and EHR vendors, but may be adapted and modified. Plans should work with auditors or contact NCQA with specific questions about the eMeasure Roadmap or Audit Roadmap Section 5.

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 ECDS If the same data source is used as ECDS and as supplemental data, are health plans required to submit separate Roadmaps/documentation?

Plans should work with their NCQA-Certified auditor to accurately identify all data sources being considered for HEDIS reporting, whether the source is used for ECDS measures or for other HEDIS domain measures. If a plan completed an Audit Roadmap (Section 5) and will use the data source for both supplemental data and ECDS, this should be noted.

This applies to the following Programs and Years:
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.

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 Transitions of Care Please clarify the September 15 FAQ stating that SNPs and MMPs are not required to report the TRC measure because it does not appear in Table 3 of the CMS reporting requirements memo. Are SNP and MMPs plans required to report TRC in their contract-level submission?

Yes. Contracts that offer SNP and MMP plan benefit packages are required to report TRC in their contract-level submission, as described in Table 2 of the CMS HEDIS 2018 Reporting Requirements memo.

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 ECDS May we use depression screening performed by case managers who are employees of a health plan and are not part of an external provider group directly serving the member?

Yes. Data collected by care/case managers employed by a health plan are appropriate, and are reported in the Case Management category in the measure report.

Care/case managers are considered part of the member’s care team because they help members manage a condition and/or their use of health care services.

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 ECDS Clarify “data must be accessible by the health care team at point of care.”

To qualify for HEDIS ECDS reporting, practitioners/practitioner groups that are accountable for clinical services provided to members must be able to access all ECDS data used by a health plan for quality measure reporting.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.

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 ECDS For IP-ECDS coverage, does NCQA look for the number of members in the initial population?

IP-ECDS coverage count includes all members in the initial population who are being managed by at least one provider with the capacity to send, receive and use electronic data for quality improvement purposes.The Initial Population includes all members (covered and not covered by ECDS) who are identified as eligible for the measure reported by the data source category used to determine eligibility.

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 ECDS If case management data are used only by behavioral health-care providers (not by primary care providers), may these data be an ECDS data source?

Case management data may be used for measures using the ECDS reporting method if the information collected by case managers is available on request to all providers treating the same member in another setting. 
Data are not required to be accessed to qualify for ECDS reporting, but must be available on request to providers providing care to the member.

This applies to the following Programs and Years:
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.

This applies to the following Programs and Years:
HEDIS 2018