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 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

12.09.2016 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.

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 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment When determining the IESD for an ED visit that results in an inpatient stay, the IESD is the date of the inpatient discharge. Is an AOD diagnosis required for the inpatient stay and for the ED visit?

No. An AOD diagnosis is required for the ED visit, but not for the inpatient stay.

HEDIS 2017

11.15.2016 Immunizations for Adolescents (IMA) For the Immunizations for Adolescents (IMA) measure, are issuers required to report Combination 1 for the Quality Ratings System?

No. HEDIS for QRS requires collection of only Combination 2 and related antigens. IMA will not be scored this year.

Exchange 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

11.15.2016 Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence Table FUA-1/2/3, on page 179 of the HEDIS 2017, Volume 2 Technical Specifications, indicates that the Eligible Population is collected at the measure level. Should it also be collected for each of the two rates for each age stratification and for the total?

Yes. Replace the “ü” in the “Eligible Population” row with “Each of the 2 rates for each age stratification and total.” This is how the Eligible Population will be collected in IDSS.

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 Prior Year’s Validated Historic Hybrid Medical Record Results How should prior year’s validated historic hybrid medical record results be flagged for HEDIS 2017, given their removal from the supplemental data list?

Prior year’s validated historic hybrid medical record result files were removed from Section 5 (Supplemental Data) of the HEDIS Roadmap and are now listed as a data source used for reporting in Section 7 (Data Integration). Because of this change, these data should be loaded as administrative data, rather than as supplemental data, as in the past and should be considered administrative hits. This applies only to the previous year’s validated hybrid data, not to all medical record data or medical record data previously approved as supplemental data.

HEDIS 2017

10.15.2016 Follow-Up After Care for Children Prescribed ADHD Medication In the Technical Update memo, the reference to “February 28” in the Intake Period definition was replaced with “February 29” because 2016 is a leap year. Should organizations make the same change to the “Ages” criteria in the Eligible Population of Rate 1 and Rate 2?

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

10.15.2016 Comprehensive Diabetes Care In the Technical Update memo, the list of bullets when identifying BP readings to not include were revised in the Controlling High Blood Pressure (CBP) measure. Should organizations make the same change to the Comprehensive Diabetes Care (CDC) measure?

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