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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4.15.2013 Look-back period for delegation agreements and pre-delegation assessments of Interim Eos What is the look-back period for delegation agreements and predelegation evaluations for organizations coming through for Interim Surveys?

For Interim Surveys, the look-back period for delegation agreements and predelegation evaluations is 6 months.

This applies to the following Programs and Years:

3.16.2013 Encounter Rate by Service Type (ENRST) Table ENR-F in the Encounter Rate by Service Type measure has instructions to download codes from the CMS Web site, but the referenced file is no longer on the site. The instructions refer specifically to a spreadsheet titled Addendum AA-ASC Covered Surgical Procedures (ASC_AddAA.csv) for October 2012 from the site http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html

When I click the link, it brings up a download file named "asc-october2012-aa-bb-dd1-dd2-ee.zip," which has an excel spreadsheet and 5 txt files, ASC AA, ASC BB (and so on). Are these correct? Which should we use?

3.16.2013 Evidence-Based Cervical Screening (ECS) For Measurement Year 2012, would a member who had a Pap test and an HPV test on different dates of service in 2009 or 2008 fall in Rate 1 (Appropriately Screened) or in Rate 2 (Not Screened)?

The member would fall in Rate 2 (Not Screened) because the Pap test and the HPV test occurred on different dates of service.

This applies to the following Programs and Years:

3.16.2013 General Guidelines I am a self-reporting PO who plans to submit results for Medicare members. Please clarify which health plans members I should include.

A self-reporting PO submits clinical results based on all Medicare members belonging to a participating health plan:

  • Anthem Blue Cross.
  • Blue Shield.
  • Health Net.
  • SCAN.
  • UnitedHealthcare.

This applies to the following Programs and Years:

3.16.2013 Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) In HEDIS 2013, Table ART-C includes code J3262, but P4P does not. Please confirm that it should be included.

Table ART-C should include J3262. This will be corrected in the next release of the P4P manual.

This applies to the following Programs and Years:

3.15.2013 Eligibility for accreditation prior to establishing relationships Is an organization eligible for accreditation if it does not perform the functions specified within the standards and guidelines directly and has not entered into an effective service agreement with another entity to perform the function?

No. To be eligible for accreditation, an organization must perform the functions specified in the standards and guidelines (e.g., QI, UM, CR, RR and MEM, if applicable), either directly or through a service agreement.

This applies to the following Programs and Years:

3.15.2013 Web chat as a means of meeting MEM 4, Element A Does the availability of a Web chat meet the requirements for an attempt or contact to meet MEM 4, Element A?

Yes. As long as the member can receive the information or complete the listed activities in the element in one attempt or contact, a Web chat will meet the requirements. The organization would need to provide documentation explaining how the system works and evidence of completion of the specified actions.

This applies to the following Programs and Years:

3.06.2013 Proportion of Days Covered (PDC) The specifications state, "if the member has two distinct measurement periods in one measurement year, exclude the member due to a gap in enrollment." Please clarify.

If a member has two separate 90+ day enrollment periods during the measurement year, each with a pharmacy benefit, exclude the member due to a gap in enrollment.

If a member has two separate enrollment periods, one for fewer than 90 days, include the member in the measure but count only the 90+ day enrollment period. Use the date of disenrollment from the 90+ day enrollment period as the end of the measurement period.

If a member has two separate enrollment periods, one with no pharmacy benefit, include the member in the measure but count only the enrollment with the pharmacy benefit. Use the date of disenrollment from the enrollment period with the pharmacy benefit as the end of the measurement period.

This applies to the following Programs and Years:

2.16.2013 Care for Older Adults For the functional status assessment indicator, the fourth bullet requires notation of at least three of the four components: cognitive status, ambulation status, sensory ability and other functional independence. For "sensory ability," must all three components (hearing, vision, speech) be documented to meet the criterion?

Yes. All three components must be evaluated to fulfill the sensory ability component.

This applies to the following Programs and Years:
HEDIS 2013

2.16.2013 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents If height and weight are documented in the medical record during the measurement year, may the organization calculate BMI percentile at a later date?

Yes. The BMI percentile may be calculated by the organization at a later date. It must be calculated and documented in the medical record during the measurement year to be eligible for use in HEDIS reporting.

This applies to the following Programs and Years:
HEDIS 2013

2.16.2013 Adult BMI Assessment If the member's weight is documented in the medical record during the measurement year or year prior to the measurement year, may the organization calculate BMI at a later date?

Yes. The BMI may be calculated by the organization at a later date. It must be calculated and documented in the medical record during the measurement year or year prior to the measurement year to be eligible for use in HEDIS reporting.

This applies to the following Programs and Years:
HEDIS 2013

2.16.2013 Adult BMI Assessment May a member's weight and BMI be noted on different dates of service in the medical record?

Yes. Weight and BMI may be noted on different dates of service as long as they are documented in the medical record during the measurement year or year prior to the measurement year.

This applies to the following Programs and Years:
HEDIS 2013