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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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12.15.2016 Comprehensive Diabetes Care Organizations are instructed to exclude BPs 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). May organizations exclude BPs on the same day as a procedure that typically requires a change in diet/medication or must the medical record documentation specifically state there was a change in diet/medication?

If it is standard practice to change diet or medications prior to a procedure, then exclude BPs on the same day as that procedure. For example, a colonoscopy requires a change in diet combined with bowel prep prior to the procedure. Therefore, BPs on the day of a colonoscopy are excluded even if the medical record documentation does not contain specific notation about a change in the member’s diet. Should organizations require support in identifying procedures where a diet or medication change is standard practice, they must consult with their internal clinical staff or their HEDIS auditor.

HEDIS 2017

12.15.2016 PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults and Depression Remission or Response for Adolescents and Adults If an organization chooses to report the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS) and Depression Remission or Response for Adolescents and Adults (DRR) measures, must the data be audited?

No. The DMS and DRR measures are not required to be audited for HEDIS 2017.

HEDIS 2017

12.15.2016 Plan All-Cause Readmission Does the Note at the end of step 4 (page 347) regarding required exclusions of the denominator of the administrative specification also apply to step 3 of the numerator (page 352)?

Yes. Add the following language to step 3 of the numerator: Note: For hospital stays where there was an acute-to-acute direct transfer (identified in step 2), use both the original stay and the direct transfer stay to identify exclusions in this step.

HEDIS 2017

12.15.2016 Controlling High Blood Pressure Organizations are instructed to exclude BPs 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). May organizations exclude BPs on the same day as a procedure that typically requires a change in diet/medication or must the medical record documentation specifically state there was a change in diet/medication?

If it is standard practice to change diet or medications prior to a procedure, then exclude BPs on the same day as that procedure. For example, a colonoscopy requires a change in diet combined with bowel prep prior to the procedure. Therefore, BPs on the day of a colonoscopy are excluded even if the medical record documentation does not contain specific notation about a change in the member’s diet. Should organizations require support in identifying procedures where a diet or medication change is standard practice, they must consult with their internal clinical staff or their HEDIS auditor.

HEDIS 2017

12.15.2016 UM 9, Element D: Including Reviewers Names on Appeal Decision Letters Are organizations required to include reviewers’ names on appeal letters or verbally communicate to members that names are available upon request?

No. Organizations are not required to include reviewer names on the decision letter or verbally inform members that the information is available upon request. This language will be removed from UM 9, Element D in the March Policy update.

Please note this requirement remains in UM 8, Element A. 

HP 2017

12.15.2016 Allowing Automatic Credit for UM 13, (UM 12 in HP 2017) Elements A and B for Interim Surveys Is automatic credit available for Interim Surveys for organizations that delegate UM 13 (UM 12 in HP 2017), Triage and Referral for Behavioral Healthcare, Elements A and B to an NCQA-Accredited/Certified health plan, MBHO or UM-CR?

Yes. Automatic credit is available for an Interim Survey if the organization delegates to an NCQA-Accredited/Certified health plan, MBHO or UM-CR. The delegate’s Accreditation/Certification Survey must include the specific elements or factors for which the organization seeks automatic credit. The organization is responsible for determining if delegated activities are covered in the scope of the delegate’s NCQA review.

HP 2017

12.15.2016 Revising Data Sources for MBHO QI 7, Element A and B What are the correct data sources for QI 7, Element A and B for MBHO 2016?

NCQA reviews documented process and materials. The Policy Update posted on 11/21/16 was incorrect.

12.09.2016 VBP4P Value Set Directory It appears that the Value Based P4P Value Set Directory (VSD) released on December 1, 2016, is missing the leading zeros for ICD-9 codes in a multiple value sets. For example, 079.4 is showing as 79.4 and 042 is showing as 42. Is there a version of the VBP4P Value Set Directory that includes the correct codes?

Thank you for bringing this to our attention, select codes within the December 1 version of the Value Set Directory file contained errors; leading and trailing zeros were unintentionally dropped from ICD-9 and Uniform Bill Codes.

 

NCQA has corrected this issue and updated the impacted files in the Download Center site as of 12.08.16. To obtain the updated versions, log into Download Center with your NCQA login credentials (email address) and re-download the MY 2016 Value Based P4P Manual and Value Set Directories zip file. The updated files inside will reflect the date of 12.08.16 in the file name.

 

We apologize for any inconvenience or confusion caused by this error.

IHA 2016

11.18.2016 Immunizations for Adolescents (IMA) The Advisory Committee on Immunization Practices (ACIP) approved a 2-dose schedule for the 9-valent HPV vaccine in October 2016. Will NCQA update the Immunizations for Adolescents (IMA) measure to accommodate the new HPV vaccination schedule?

This question was forwarded to the HEDIS policy team and received the following response:

"NCQA has been monitoring ACIP’s review of the HPV vaccination schedule. Once the recommendation is published in CDC’s Morbidity and Mortality Weekly Report, the appropriate NCQA staff and panels will evaluate potential changes to the measure. HEDIS 2017 evaluates performance for calendar year 2016; measure specifications for HEDIS 2017 are final. Proposed changes, if any, will be posted for Public Comment in February 2017 and, pending final approval by the NCQA Committee on Performance Measurement, will be included in HEDIS 2018."

The VBP4P program intends to align with HEDIS; any potential changes would be reflected in the draft version of the MY 2017 Value Based P4P Manual released on September 1, 2017.

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IHA 2016

11.15.2016 Immunizations for Adolescents The Advisory Committee on Immunization Practices (ACIP) approved a 2-dose schedule for the 9-valent HPV vaccine in October 2016. Will NCQA update the Immunizations for Adolescents (IMA) measure to accommodate the new HPV vaccination schedule?

NCQA has been monitoring ACIP’s review of the HPV vaccination schedule. Once the recommendation is published in CDC’s Morbidity and Mortality Weekly Report, the appropriate NCQA staff and panels will evaluate potential changes to the measure.
HEDIS 2017 evaluates performance for calendar year 2016; measure specifications for HEDIS 2017 are final. Proposed changes, if any, will be posted for Public Comment in February 2017 and, pending final approval by the NCQA Committee on Performance Measurement, will be included in HEDIS 2018.

HEDIS 2017

11.15.2016 Standardized Healthcare-Associated Infection Ratio CMS updates the Hospital Compare information throughout the year. How can organizations ensure that they are using the same Hospital ID (Provider ID) list from the CMS Hospital Compare website when reporting the HAI measure?

NCQA will release a locked Hospital ID (Provider ID) file, along with the HAI Standard Injection Ratio (SIR) table (Table HSIR) on January 2, 2017. This will allow both the Hospital ID and the appropriate SIR to be used when reporting the measure.

HEDIS 2017

11.15.2016 Opportunity to discuss a UM request Given CMS appeal regulations (at 42 CFR §422.580), may Medicare organizations give practitioners the opportunity to discuss a UM request prior to a UM decision, to meet the requirements of UM 7, Elements A, D and G?

Yes. For the Medicare product line, the organization may give the treating practitioner an opportunity to discuss a UM request with a physician or other appropriate reviewer prior to the decision. The denial file must contain documentation of this.

HP 2017