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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11.16.2015 Risk-Adjusted Measures There are duplicate diagnosis codes in the following tables used for risk adjustment: PCR-DischCC and CC-Comorbid. Is this correct?

Yes. The risk adjustment measures are based on the CMS Hierarchical Condition Categories (HCC) risk-adjustment methodology. The updates made to the model, combined with the addition of ICD-10 diagnosis codes, changed the way clinical conditions (CCs) are assigned. When there is a duplicate diagnosis code, it is assigned to multiple CCs. For example, ICD-10 diagnosis code I132 should be mapped to both CC-85 and CC-136. Therefore, CC-85 and CC-136 should both be used towards calculating comorbid weight. In addition, for the Plan All-Cause Readmissions measure, it is possible for members to have more than one discharge CC if the primary discharge diagnosis is assigned multiple CCs.

HEDIS 2016

11.16.2015 Administrative-only Measures For administrative-only measures such as Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART), may organizations abstract medication information from the medical record to identify numerator hits?

For administrative-only measures, information abstracted from the medical record is considered nonstandard supplemental data and is subject to all requirements described in General Guideline 34. The supplemental data must include all data elements required by the measure specification. For pharmacy data, this means that all data elements from the NDC lists must be present: the generic name, strength/dose, route and date when the medication was dispensed to the member. Generic documentation in the medical record (e.g., that a patient “was prescribed” or “is taking” a medication) that does not include drug name, strength/dose and dispense date does not meet criteria.

HEDIS 2016

11.16.2015 Relative Resource Use for People With Asthma Will NCQA publicly report the Relative Resource Use for People With Asthma (RAS) measure for the Medicare product line for HEDIS 2016?

No. Due to the addition of the Medicare product line to the RAS measure, this measure will not be publicly reported for the Medicare product line for HEDIS 2016. The commercial and Medicaid product lines for RAS will continue to be publicly reported for HEDIS 2016.

HEDIS 2016

10.15.2015 Complaints and Appeals Analysis for Marketplace product line May an organization submit one report for all its product lines, including its Marketplace product line?

The organization may submit one analysis report for all its product lines, including Marketplace, but the analysis for the Marketplace line must be separate in order to receive credit for QI 12, Element C.

10.15.2015 Delegation revocation and documentation If an organization revokes delegation, may the organization receive “NA” scoring if the delegate does not provide the necessary documentation?

No. The organization is responsible for meeting NCQA requirements even if it terminates the delegation agreement.

10.15.2015 Technical Update In the Technical Update memo, the following language was added to Persistence of Beta-Blocker Treatment After a Heart Attack and Follow-Up After Hospitalization for Mental Illness: “Use only facility claims to identify discharges and diagnoses for denominator events (including readmissions or direct transfers). Do not use professional claims.” For other measures that use the same method and value sets to identify a discharge (or an admission), should the organization use both facility and professional claims?

Yes. Unless the measure specification directs otherwise, use diagnosis and procedure codes from both facility and professional claims to identify an admission or discharge event.

HEDIS 2016

10.15.2015 Childhood Immunization Status When abstracting medical record data for the hepatitis B vaccine, must the rules for the newborn hepatitis B vaccination in the administrative specification be followed?

When abstracting hepatitis B vaccine data from the medical record, there is no requirement that one be a “newborn” vaccine specifically, and there are no date restrictions. For hybrid reporting, when all events come from the medical record, documentation of three hepatitis B vaccines administered on three different dates of service meets criteria.

The newborn hepatitis B vaccine instructions and value set are intended to be used only for administrative data. The rules for the newborn hepatitis B vaccine are in place because the code in the Newborn Hepatitis B Vaccine Administered Value Set is a generic code that indicates a vaccine was administered but it does not indicate which vaccine was administered (it is not specific to hepatitis B). If this code occurs during the eight-day period (date of birth plus 7 days) then it is appropriate to assume it was a hepatitis B vaccine that was administered (since this is the only vaccine that is routinely administered to all children before discharge from the hospital).

HEDIS 2016

10.15.2015 Off-Marketplace in Accreditation If Off-Marketplace plans are not required by CMS to be in QRS, are they still required to include their membership in commercial product line when submitting for health plan accreditation?

Yes, Off-Market plans are required to be in the commercial product line when submitting for health plan accreditation.

10.15.2015 P4P Overview In the draft version of the MY 2015 Value Based P4P Manual released on 9/1/2015, page 6 indicates that the PO deadline for supplemental data collection is February 15, 2016, and the supplemental data validation deadline is March 15, 2016. Under the Supplemental Data Validation Deadline Activity, the last sentence states “Primary source verification (PSV) for member-reported and nonstandard supplemental data must not occur prior to March 2 unless the organization finished all supplemental data processes, collection and entry.”
Should the last sentence be updated to say February 15 instead of March 2?

Yes, you are correct; the date in the last sentence under Supplemental Data Validation Deadline should state:

“Auditor finalizes approval of all supplemental data. Primary source verification (PSV) for member-reported and nonstandard supplemental data must not occur prior to February 15 unless the organization finished all supplemental data processes, collection and entry.”

We will update this for the final version of the MY 2015 Value Based P4P Manual, released on December 1, 2015.

IHA 2015

10.15.2015 Oral notification of expedited appeal decisions UM 5 allows organizations to provide initial oral notification for urgent requests, with written notification within three calendar days. Does this also apply to expedited appeal decisions in UM 9, Element B?

Yes. Organizations may provide oral notification, followed by written/electronic notification within three calendar days.

UM-CR 2013

9.30.2015 QRS and Off-Market Commercial HEDIS Submission Should Off-Marketplace plans include their membership in QRS and in Marketplace accreditation?

No. Off-Marketplace plans should include its membership in its commercial HEDIS submission and in its commercial product line when submitting for health plan accreditation.

Exchange 2016

9.15.2015 Documentation requirements for file review when delegating to a certified CVO What documentation must an NCQA-Certified CVO provide to an organization for an accreditation survey file review?

The organization and the CVO determine the documentation methods for reporting information. Acceptable methods include a checklist, the actual documents and access to electronic credentialing files. When an organization delegates to a certified CVO, NCQA reviews the organization’s credentialing files to assess timeliness and ascertain whether the credentialing decision was made within the specified time limits (i.e., 180 calendar days from verification).

CVO 2013