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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5.01.2015 Specific Regulatory Actions to be Reported What specific regulatory actions must be reported?

The organization must report the occurrence of any of the following actions by any federal or state regulatory authority:

  • Issuance of Intermediate Sanctions and/or suspension of enrollment by CMS or any other federal or state regulatory authority.
  • Issuance of any fine equal to or exceeding $50,000 related to Organization’s operations by CMS or any other federal or state regulatory authority.
  • Issuance of any request for a corrective action by any federal or state regulatory authority where the substance of such corrective action relates to the Organization’s handling of utilization management decisions, network adequacy, benefit denials, complaints, grievances, appeals or other important patient safety matters. 

The above actions are referred to as the “final determination” within the Agreement.

CM 2014

5.01.2015 Reporting Regulatory Actions Are health plans required to report regulatory actions taken against the organization?

Yes. The Agreement for Health Plan Accreditation Survey (the “Agreement”), specified in the “Organization’s obligations” section of the standards and guidelines, requires the organization to provide NCQA written notice within thirty (30) calendar days of the final determination by a state or federal agency with respect to request for corrective action, imposition of sanctions, changes in licensure or qualification status, if applicable, or violation of any federal or state law that affects the Scope of Review under the Standards and Guidelines. These are termed Reportable Events.

CM 2014

4.16.2015 Policy Clarification Support (PCS) Website URL Is there a new Web site URL for the PCS system?

Yes. The PCS system will be moved to a new Web site—http://my.ncqa.org—by the end of April. Customers who access the old PCS site will be automatically rerouted to the new site. The new site takes the same login and password; you will not need to change them.

HEDIS 2015

3.19.2015 Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Is QRS Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) collected using the hybrid method or the administrative method?

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life should be reported using only the administrative methodology as specified in the 2015 QRS Technical Specifications (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/2015-QRS-Measure-Technical-Specifications.pdf). Hybrid specifications are not available for this measure in the QRS.  The W34 measure is listed as a measure in the sample size table of the QRS Sampling Guidelines and was a misprint which will be corrected in the 2016 QRS Measure Technical Specification.
 
For organizations who have started medical record review for W34, please note, the IDSS will only accept the administrative elements of the measure for QRS.

Exchange 2015

3.15.2015 Eligibility for Automatic Credit Is an organization eligible for automatic credit if its accredited delegate has a single practitioner network with centralized credentialing (i.e., one credentialing committee; the same staff handle all practitioner credentialing) for all product/product lines, but is not accredited for the delegated product line?

Yes. Because the organization uses the same practitioner network for all product/product lines, and all practitioners are subject to CR file review during an NCQA Accreditation Survey, the file is eligible to receive automatic credit. This is an exception to the Product Match policy posted on Policy Updates page.

3.15.2015 HEDIS Reevaluation Does the new 2015 HPA annual HEDIS evaluation policy apply to organizations surveyed on or before June 30, 2015?

No. Organizations with submissions before July 1, 2015, are reevaluated on the HEDIS measures in effect at their last survey. Organizations submitting after June 30, 2015, are reevaluated on the HEDIS measures in effect for that reporting year.

3.15.2015 Chief nursing officer approves clean nurse-practitioner files May a chief nursing officer, who is a nurse practitioner, review and approve clean nurse-practitioner files in lieu of a medical director?

Yes. Nurse practitioners acting as chief nursing officers may approve clean files in states where nurse practitioners can practice independently, or independently with a collaborative physician arrangement.

3.13.2015 Meaningful Use of Health IT An FAQ about e-measure reporting posted on 1/29/15 states, “You should use the same definition of PCP as outlined in the NPI data file specification instructions. Providers in your denominator should include employed and contracted PCPs (MD or DO) in the following specialties: Family/General Practice, Internal Medicine and Pediatrician/Adolescent Medicine.”
The Controlling High Blood Pressure e-measure is specified for members 18 years and older, should pediatricians be excluded from the denominator?

POs have the option of excluding pediatricians from the Controlling High Blood Pressure e-measure denominator.

IHA 2014

3.13.2015 Proportion of Days Covered by Medications (PDC) An answer to an FAQ posted on 2/17/15 states, “Exclude members whose ESRD diagnosis is noted any time during the measurement year.”
The MARx System output, which contains the RxHCC codes, does not release the entire 2014 dates of service until after the IHA reporting deadline. Does the FAQ apply to both the RxHCC and ICD-9-CM code?

The intent is to use the most current information for the ESRD exclusion. If ICD-9-CM is used, then any code from the value set during the measurement year excludes the member from the denominator. If the MARx System output is used, then the most recent version applies. Although the time frames are not consistent between ICD-9-CM and RxHCC, it is the most current information to identify patients with ESRD. ICD-9-CM is preferred, but if it is not available, the most current MARx System output can be used.

IHA 2014

3.13.2015 High Risk Medication (HRM) According to the last paragraph on page 149, plans and POs should use the first two prescription fills to calculate average daily dose to determine numerator compliance. Should other fills during the treatment period be considered when calculating average daily dose?

Yes, all fills during the treatment period should be considered. Calculate the average daily dose for each High-Risk Medication fill using the formula (quantity dispensed x dose)/(days supply). If the average daily dose for any two fills of the HRM exceed the threshold, then the member is numerator compliant.

IHA 2014

2.26.2015 Relative Resource Use for People With Diabetes In the Quality Ratings System (QRS) Measure Technical Specifications, the RRU General Guidelines reference 13 risk groups, but there are only 8 risk groups referenced in Table RDI-B-4: Data Elements for Relative Resource Use for People With Diabetes. Which is correct?

Table RDI-B-4 should include all 13 risk groups, to match the RRU General Guidelines in the QRS technical specifications.

Exchange 2015

2.17.2015 Evidence Based Cervical Cancer Screening (ECS) The service date example in Rate 2, step 2 states, “If the service date for cervical cytology was November 27 of the measurement year, the HPV test must include a service date on or between December 1 and December 5 of the measurement year.” This does not align with the other service data examples in Rate 1 and Rate 3 of the Administrative Specifications. Should the service dates in Rate 2, step 2 align with the other examples?

Yes. The service date example in Rate 2, step 2 should align with the examples in Rate 1 and Rate 3. The dates were inadvertently switched in the Rate 2 example and should state:

“For example, if the service date for cervical cytology was December 1 of the measurement year, the HPV test must include a service date on or between November 27 and December 5 of the measurement year.”

IHA 2014