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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9.15.2011 Text under Complaint and Appeal Categories The following text has been added to Billing and Financial Issues under the Complaint and Appeal Categories subhead: (1) Appeals for denials of out-of-network services where members are balance billed (2) Physicians who code the claim incorrectly (3) Practitioners who balance bill members for services (4) Disputes of deductibles and copayments. Are these new requirements?

No. These are not new requirements. They are examples of billing/financial issues. The text was inadvertently added to the Explanation and will moved to the Examples in the November 21, 2011 Policy Update.

9.15.2011 Types of Delegates What types of delegates are reviewed in MA 21?

All delegates that have been delegated activities included in the HP Medicare Advantage Deeming Module are subject to review under MA 21. Delegates that handle non-deemable activities are not within the scope of review for MA 21.

9.15.2011 Options for Denied Accreditation What options are available for organizations that have been denied accreditation, but still want to become accredited?

An organization may reapply for accreditation one year after the date when it receives the Denied status, or it may request an Expedited Survey if it has corrected the issues that led to the denial of accreditation. Upon receipt of the organization's written request, NCQA may grant an Expedited Survey in six or nine months of the Denied status if the organization demonstrates that the issues can be corrected within the six-to-nine month time frame and the corrective actions undertaken would raise the organization's accreditation status. (Refer to Policies and Procedures – Section 2: The Accreditation Process, for more information)

5.16.2011 Removal of Chronic Care Improvement Projects (CCIP) and Quality Improvement Projects (QIP) from Deeming CMS recently announced that CCIPs and QIPs are no longer deemable. Will you continue to review organizations against these requirements?

No. We have been instructed by CMS to stop reviewing these requirements. Effective immediately, MA 13 and MA 18 will be scored NA.

5.16.2011 Use of Performance-based Improvement Module (PIM) Element A states that If an organization takes action based on physician completion of an ABMS or AOA board performance-based improvement module generally in conjunction with maintenance of certification) at least every two years, those activities may be used as a quality measure for the purposes of meeting this standard. When counting the quality measures for Element A, for how many measures does NCQA award credit (e.g. for each measure in the PIM or for each PIM)?

Regardless of the number of measures within a PIM, each PIM counts as one standardized measure for PHQ 1, Element A. This is consistent with the current language in the PHQ standards and guidelines (i.e., activities may be used as a measure). To receive credit for using PIMs and for the survey team to verify that the Board requires a PIM as part of certification maintenance, the organization must list in the Survey Tool's Element A Measure Worksheet: (1) the PIMs on which it bases the action; (2) list the source of the measures as Specialty Medical Boards; and (3) provide a direct link to the Board where the PIM and its measures can be found.

5.16.2011 General Guidelines If a DM organization does not meet the 15,000 minimum enrollment threshold, may it submit DM measure results to NCQA to be scored as a part of accreditation?

Yes. NCQA is lowering the enrollment threshold for DM 2012 and allowing optional reporting for organizations that do not meet this requirement. Because the threshold will change next year, DM organizations that do not meet the threshold may report in 2011 and earn the Accredited With Performance Reporting status.

4.16.2011 Measure Specifications NCQA requires that an organizations measure specifications exactly match the specification of the standardized measure in order to receive credit for PHQ 1 A. In some cases, National Quality Forum (NQF)) or Ambulatory Quality Alliance (AQA) may have endorsed or accepted a measure specification which has subsequently been updated by the measure developer based on changes to underlying clinical evidence, coding, etc. If NQF or AQA have not yet updated the endorsement/acceptance, does the organization still receive credit if it is using the most recent specification from the measure developer?

Yes. An organization that uses the most current specifications from the measure developer meets the intent of PHQ 1, Element A for that measure, even if the NQF or AQA acceptance/endorsement has not been updated.

4.16.2011 Quality assessments for Organizational Providers Must organizations conduct an onsite quality assessment of non-accredited providers?

No. Organizations must conduct a quality assessment of nonaccredited providers, but the quality assessment does not need to occur onsite for MA Deeming Surveys.

1.17.2011 Prenatal and Postpartum Care The LOINC codes listed for rubella for Decision Rule 3 in Table PPC-C are inconsistent with the LOINC codes listed for rubella in other sections of Table PPC-C. Is this accurate?

No. LOINC codes listed in the Rubella/ABO/Rh category for Decision Rule 3 should match the LOINC codes listed in other categories (e.g., the LOINC codes listed for the Rubella/ABO/Rh category in Decision Rule 2).

1.17.2011 Comprehensive Ischemic Vascular Disease Care CPT Category II code 3076F became obsolete January 1, 2007. Should it be deleted from Table IVD-G?

Yes. Delete the code from Table IVD-G.

1.17.2011 Comprehensive Ischemic Vascular Disease Care Should CPT Category II codes 3074F and 3075F be included in Table IVD-G?

Yes. 3074F (systolic less than 130 mm Hg) and 3075F (systolic 130_139 mm Hg) were inadvertently removed from Table IVD-G, but they should be included because they define BP systolic levels of less than 140 mm Hg.

11.15.2010 Use of the term "days" within the Standards & Guidelines Do all references to "days" in the standards and guidelines mean "calendar days"?

Yes. Unless otherwise specified, all references to "days" in the standards and guidelines mean calendar days.

PHQ 2013