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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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10.16.2023 Explanation of Benefit (EOB) The digital measure packages for MY 2024 include “Explanation of Benefit” (EOB) criteria. What does that mean?

Although HEDIS digital measure logic references “Explanation of Benefit (EOB),” this is not referenced as a data source in HEDIS Volume 2. In FHIR, the EOB resource represents claims that have been adjudicated, and includes data elements from both Claim and ClaimResponse. The digital logic was written to include the Claim/ClaimResponse resource for claims that are still processing; the ExplanationOfBenefit resource is for claims that are adjudicated.

HEDIS 2024

10.16.2023 Credentialing application question about present illegal drug use (CVO) Would the following question on a credentialing application meet the intent of CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2? “Are you currently using illegal drugs that could affect your ability to practice medicine?”

Yes. NCQA uses language in the Explanation that organizations may use more general or extensive language to query practitioners about impairment.

Note: This question was previously posted on August 15, 2023 and reevaluated by NCQA. This FAQ answer replaces the previously posted response.

CVO 2022

10.16.2023 CAQH Application: Illegal drug use question Does the CAQH application question about lack of current illegal drug use meet the intent of NCQA’s requirement in CR 3, Element C, factor 2?

Yes, the following CAQH question meets the intent of the requirement in CR 3, Element C, factor 2:

“Are you currently engaged in the illegal use of drugs?* ("Currently" means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.)"
 
CAQH provides additional information regarding what "currently" means that aligns with language in the explanation of CR 3, Element C, factor 2 that the organization may use more general or extensive language to query practitioners about impairment.

HP 2024

10.16.2023 UM 13, Element C, factor 2 for mail service delegates Can organizations submit a mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit for UM 13, Element C, factor 2?

Yes. Organizations may submit the mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit. This is not required to be specified in the delegation agreement.

HP 2024

10.16.2023 External organizations providing print services only Does NCQA consider it delegation if an organization contracts with an external organization that provides print services only and does not provide mail services?

No. An organization that only provides print services is not considered a delegate or a vendor, and is outside the scope of NCQA requirements.

HP 2024

10.16.2023 Updated: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?

Yes. Using UM 13: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 13, Element A: Delegation Agreement

  • Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution (e.g., UM 11, Element B (annual updates for pharmaceutical restrictions/preferences).
    • Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance, if applicable.
    • Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
  • Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.

UM 13, Element C: Review of the UM Program:

  • Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates.
  • Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
    • Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).

Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit.  This must be specified in the delegation agreement.

Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.

HP 2024

10.16.2023 UM 12, Element C, factor 2 for mail service delegates Can organizations submit a mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit for UM 12, Element C, factor 2?

Yes. Organizations may submit the mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit. This is not required to be specified in the delegation agreement.

MBHO 2023

10.16.2023 CAQH Application: Illegal drug use question (CVO) Does the CAQH application question about lack of current illegal drug use meet the intent of NCQA’s requirement in CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2?

Yes, the following CAQH question meets the intent of the requirement in  CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2:

Are you currently engaged in the illegal use of drugs?* ("Currently" means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.)"

CAQH provides additional information regarding what "currently" means that aligns with language in the explanation of CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2 that the organization may use more general or extensive language to query practitioners about impairment.

CVO 2022

10.16.2023 Updated: MBHO: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?

Yes. Using UM 12: Delegation of UM as an example, the following describes factors that would be considered NA:

UM 12, Element A: Delegation Agreement

  • Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution
    • Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance.
    • Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
  • Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.

UM 12, Element C: Review of the UM Program

  • Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates
  • Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
    • Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).

Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit. This must be specified in the delegation agreement.

Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.

MBHO 2023

10.16.2023 Credentialing application question about present illegal drug use Would the following question on a credentialing application meet the intent of CR 3, Element C, factor 2? “Are you currently using illegal drugs that could affect your ability to practice medicine?”

Yes. NCQA uses language in the Explanation that organizations may use more general or extensive language to query practitioners about impairment.

Note: This question was previously posted on August 15, 2023 and reevaluated by NCQA. This FAQ answer replaces the previously posted response.

HP 2024

10.16.2023 Use of organization-level documentation for Health Equity Accreditation If an entity seeking Health Equity Accreditation is part of a larger organization (e.g., corporate parent) that is not seeking Accreditation, can the entity use documentation at the larger organization level to meet Accreditation requirements?

It is acceptable to use larger organization-level documented processes or policies and procedures to meet applicable requirements (e.g., for HE 1, Element A, factor 1) if the entity seeking Accreditation demonstrates that it follows the same processes. However, the entity seeking Accreditation must provide documentation that pertains specifically to its organization for requirements that require action or implementation of such processes (e.g., for HE 1, Element A, factors 2 and 3).

HEA 2024

10.16.2023 UM 13, Element C Exceptions Is the Exceptions section language in UM 13, Element C going to be updated for mail service organizations?

Yes. The following updates to the Exceptions section language are effective immediately and will be included in a Policy Update in November 2023.
This element is NA if:

  • The organization does not delegate UM activities.
  • Delegation arrangements have been in effect for less than 12 months.

Factor 1 is NA for mail service delegates.
Factors 2–6 are NA for Interim Surveys.
Factors 3 and 4 are NA if a mail service delegate distributes information for an element with an annual frequency. The delegation agreement in Element A must outline the frequency for reviewing the delegate’s reports (i.e., annual or semiannual) (UM 13, Element A, factor 4).
Factors 5 and 6 are NA if the delegate only provides cloud-based UM data storage functions and does not provide services that create, modify or use UM data.
Factors 5 and 6 are NA for mail service delegates that:

  • Provide print mail service only. 
  • Do not have access to the organization’s UM system. 
  • Do not have a UM system of their own.
  • Do not modify or store the UM data sent by the organization. 
  • Return UM data provided by the organization.

All bullets must be addressed in a delegation agreement for factors 5 and 6 to be NA.
Factor 6 is NA if the organization did not identify any date modifications or if all identified date modifications met the delegation agreement or the delegate’s policies and procedures.

Note: The strikethrough text indicates changes to the Exceptions section.

HP 2024