FAQ Directory

No. Data collection methodology must be sound enough to produce valid and reliable results but achievement of significant improvement is not required for QI 10 Element A.

This applies to the following Programs and Years:

No. More than one practitioner must be involved in QI program activities. Participating practitioners must represent a broad spectrum of specialties, as appropriate.

This applies to the following Programs and Years:

In MY 2011, health plans may submit results for the Medicare product line and for the commercial product line. Because the Medicare product line is now reported by health plans, the Health Plan Clinical and Testing Measure file layouts have three tabs for the possible reporting scenarios (commercial HMO/POS and Medicare, commercial HMO/POS only, Medicare only).

Scenario 1: The health plan has both commercial HMO/POS and Medicare product lines

Clinical Measure File Layout: Plans that report for both the commercial HMO/POS and Medicare populations must have 66 clinical measure IDs per DMHC ID/Sub Unit, even if an individual PO has only commercial or Medicare enrollment.

Testing Measure File Layout: Plans that report for both the commercial HMO/POS and Medicare populations must have 31 clinical measure IDs per DMHC ID/Sub Unit, even if an individual PO has only commercial or Medicare enrollment.

Refer to Tab (5) Sample HP FileBoth Commercial and Medicare

Examples 1_3: The plan has commercial and Medicare product lines; Pos 11111-00, 22222-03, 22222-05 and 33333-05 also have commercial and Medicare members: the plan submits commercial and Medicare data for these Pos.

Example 4: The plan has commercial and Medicare product lines; PO 44444-01 has only Medicare members: the plan submits Medicare data for PO 44444-01 and populates commercial rows for PO 44444-01 with zero enrollment, zero denominator, zero numerator and rate NB.

Scenario 2: The health plan has commercial HMO/POS product line only

Refer to Tab (6) Sample HP FileCommercial Only: Plans that have the commercial product line only submit data for the commercial product. There are no rows for the Medicare product.

Clinical Measure File Layout: The plan reports 59 clinical measure IDs per DMHC ID/Sub Unit for the commercial product.

Testing Measure File Layout: The plan reports 10 testing measure IDs per DMHC ID/Sub Unit for the commercial product.

Scenario 3: The health plan has Medicare product line only

Refer to Tab (7) Sample HP FileMedicare Only: Plans that have the Medicare product line only submit data for the Medicare product. There are no rows for the commercial HMO/POS product.

Clinical Measure File Layout: The plan reports 7 clinical measure IDs per DMHC ID/Sub Unit for the Medicare product.

Testing Measure File Layout: The plan reports 21 clinical measure IDs per DMHC ID/Sub Unit for the Medicare product.

This applies to the following Programs and Years:

For MY 2011, POs should use their own designation of PCPs. This is in alignment with how P4P had defined PCPs for the IT-Enabled Systemness Domain.

This applies to the following Programs and Years:

For the MUHIT domain, intent refers to the measures criteria, as specified in the Intent section. For Required Submission item 4, count the number of PCPs, or the number of patients assigned to PCPs who meet the criteria listed for each measure. Assign the number of points that correspond to the percentage of PCPs meeting the measures intent.

This applies to the following Programs and Years:

No. For the MUHIT domain, functionality means a fully operational and implemented system that has been in use since October 1, 2011. An organization that has an EHR in place, but is not using it as defined in the measure intent statement, does not receive any points for that measure.

This applies to the following Programs and Years:

For MY 2011 P4P tables CWP-C and URI-D, crosswalk to the HEDIS 2012 NDC list for table CWP-C.

*Note: The MY 2011 P4P crosswalk to HEDIS 2012 NDC List posted on December 8, 2011, has been corrected.

This applies to the following Programs and Years:

An organization must provide documentation that the community hospital/clinic meets DEA requirements. The organization must also include evidence of verification of the facility DEA in the credentialing file.

This applies to the following Programs and Years:

It is not necessary for a behavioral healthcare practitioner to be an organization employee. Organizations may use an external consultant.

This applies to the following Programs and Years:

The answer depends on whether the organization presents sanction information every 30 days to its Credentialing Committee. If so, there is no need to report it at the time of recredentialing. If not, the organization would need to verify and present adverse information to the Credentialing Committee at recredentialing.

This applies to the following Programs and Years:

No. Add-on personal care services do not fall within the scope of UM 4-UM 7, but they can be appealed under RR 2 or UM 8 and UM 9. Personal care services that are a part of the medical benefit fall within the scope of medical necessity review if an assessment must be done to determine the member is eligible for the services or if the services will be covered. In such cases, the services would be within the scope of UM 4-UM 7.

This applies to the following Programs and Years:

Factor 4 is scored "NA" if a plan issues a Notice of Denial of Medical Coverage (NDMC) for non-inpatient medical services denials for Medicare members.

This applies to the following Programs and Years: