FAQ Directory

Exclude members whose ESRD diagnosis is noted any time during the measurement year.

IHA 2014

Yes, the RxHCC code system and code were added to the Value Set Directory when we created the ESRD Status Value Set. This code is used to identify patients with ESRD for the denominator exclusion in Diabetes: Appropriate Treatment for Hypertension and Proportion of Days Covered by Medications.

The RxHCC code can be found in the CMS Medicare Advantage and Prescription Drug System (MARx), which provides a monthly report of members’ RxHCCs to plan sponsors. For MY 2014, use the 2013 model software of the RxHCC system. 

IHA 2014

No. The two additional rates were inadvertently left out of the clinical file layouts. Three rates should be reported for this measure:

• The percentage of non-diabetic members 18-59 years with a diagnosis of hypertension whose blood pressure was adequately controlled (<140/90 mm Hg) during the measurement year.
• The percentage of non-diabetic members 60-85 years with a diagnosis of hypertension whose blood pressure was adequately controlled (<150/90 mm Hg) during the measurement year.
• The total rate.

Revised Clinical File Layouts have been posted for health plans and physician organizations (http://iha.org/manuals_operations_2014.html), to reflect this change.

IHA 2014

CR 3–CR 6, credentialing verification activities do not count as quality measures for QI 12, Elements A and B. However, an organization may receive credit if its credentialing process incorporates clinical quality measures from NCQA (or other accreditors), the National Quality Forum (NQF), national medical boards (ABMS or AOA) or other quality measurement development sources. The organization may also incorporate member experience and cost-related measures into the credentialing process.

Yes. The intent of this requirement is to provide consumers with quality information about Marketplace Silver Plans in order to help them make a better informed choice during enrollment. Therefore, organizations to be transparent about whether they used quality, member experience or cost-related measures when selecting practitioners or hospitals to participate in its networks.

The intent of QI 12, Element C, factor 3 is that the organization collects data to understand how out-of-network services are used, whether or not members must make a formal request to use them. Therefore, NCQA considers “request for” and “use of” to be interchangeable terms. For POS products where members are not required to obtain authorization, the organization may use claims data, UM data (e.g., post-service request) or similar data.

Yes. QI 12, Element A applies even if all practitioners are available to all product lines. To receive credit, the organization’s directory must state that the organization does not use quality, member experience or cost-related measures when selecting practitioners to participate in its Marketplace Silver Plan.

No, factor 3 does not apply. Organizations must provide documentation that they contract only with these types of networks and do not limit access to any practitioners for the Marketplace Silver Plan.

The hospital directory must contain quality data from recognized national or state sources, or a link to recognized-source quality data specific to each hospital, if the link exists. If linking to the data is not technically possible (e.g., because of a requirement to accept terms of agreement), a link to the quality data landing page is acceptable. A link to the source’s general Web site home page does not meet the requirement.
 
 

To receive credit, the organization’s directory must state that the organization does not use quality, member experience or cost-related measures when selecting practitioners to participate in its Marketplace Silver Plan.

NCQA does not require the organization to collect and analyze a full year of data. For First Surveys, the look-back period is “at least once within the past year” for elements requiring annual data collection and analysis. The requirement is met if an organization collects and analyzes the data within a year of submitting the Survey Tool.

The MUHIT domain comprises three rates, the first is the percent of providers who have attested to the national or state Meaningful Use EHR Incentive programs, and the second two are e-measures. To receive credit, POs must report:

• A .csv file with a list of the PO’s providers’ national provider identifiers (NPIs). Instructions on file requirements were sent on January 7, 2015, and were discussed on the January 14–15 Webinars.
• The two e-measures, Controlling High Blood Pressure and Screening for Clinical Depression and Follow-Up Plan.
  • For self-reporting POs, these measures are reported via the PO Clinical File Layout (http://iha.org/manuals_operations_2014.html). There is a separate file layout provided for non-self-reporting PO submission.
  • For each measure, two metrics are collected:
    • The percentage of providers who can report the e-measure.
    • The aggregated numerator and denominator, for providers who can report the e-measure.

To calculate, pull the numerators and denominators from the EHR systems of all providers who can report the measures; specifications are programmed in the certified EHR systems of providers who can report. Refer to pp 150–152 of the MY 2014 P4P Manual, released December 1, 2014.

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. As with the NPI file submission, POs have the option of excluding providers who were with the PO for less than six months of the measurement year. 

IHA 2014