FAQ Directory

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:

Yes. If the member does not answer the call-back, it is counted as abandoned. If the member answers the call-back and the reports show the results, the call is not counted as abandoned because the member was kept in the queue.

For timeliness (Element C, factor 1), because it is unlikely that the system would start the call-back process before 30 seconds, the call counts as answered outside the 30 seconds.

This applies to the following Programs and Years:

Yes. If the member does not answer the call-back, it is counted as abandoned. If the member answers the call-back and the reports show the results, the call is not counted as abandoned because the member was kept in the queue.

For timeliness (Element C, factor 1), because it is unlikely that the system would start the call-back process before 30 seconds, the call counts as answered outside the 30 seconds.

This applies to the following Programs and Years:

Yes. If the member does not answer the call-back, it is counted as abandoned. If the member answers the call-back and the reports show the results, the call is not counted as abandoned because the member was kept in the queue.

For timeliness (Element C, factor 1), because it is unlikely that the system would start the call-back process before 30 seconds, the call counts as answered outside the 30 seconds.

This applies to the following Programs and Years:

PDC measures are calculated through use of paid, nonreversed claims for target medications. If the drug claims dataset contains claim reversals (and paid claims that were reversed), analysts must ensure that the reversed claims are not used to calculate PDC. Claim reversals can be identified through multiple methods because there may be multiple fields in a drug claim that indicate whether it is a reversal. Many drug claims datasets have a Count field that contains a 1 for a paid claim and a -1 for a claim reversal. The dataset may also have a field called Reversal that contains a Y if the claim is a reversal claim, or an N if it is not a reversal. Reversal claims typically have a negative quantity and a negative cost.

The claim reversal (-1 in the Count field or Y in the Reversal field) may have a Claim Number that is identical to the original claim being reversed. If the Claim Number for the reversal claim is not identical to the Claim Number for the original claim, analysts can create coding logic that will identify the reversed claim as immediately preceding the claim reversal. This latter approach is not usually necessary because most drug claims datasets allow a claim reversal to be linked to an original claim.

This applies to the following Programs and Years:

In the first scenario, the index date is 74 days prior to the end of the measurement period, so the member should be excluded. In the second scenario, the index date is 61 days prior to the end of the measurement period, so the member should be excluded.

This applies to the following Programs and Years:

In your example, the measurement period is 180 days (January 1_June 30). Step 2 of the numerator criteria reads, "within the measurement period, count the number of days the member was covered." In this case, look for covered days from January 1_June 30; in essence, the numerator is being capped. The PDC is not calculated by summing the days supply for pharmacy claims. You may need to set up a time array for each claim, to identify the time frame covered by each fill, then count the number of days in the measurement period that are covered by the time arrays. Thus, the numerator may not exceed the denominator for the person-level PDC calculation. Refer to the attached example for SAS code for arrays.

This applies to the following Programs and Years:

Yes, although because MUHIT is scored at the measure level, PCPs might receive credit for some measures and not for others.

This applies to the following Programs and Years:

For this exclusion, look back as far as possible in the members history.

This applies to the following Programs and Years:

Sixty days are covered. The first prescription lasts 30 days, starting January 1. If you move the next prescription's start date to the day after the previous fill has ended, it becomes January 31. The end date is March 1. In essence, the start date and the end date of the second prescription both move.

This applies to the following Programs and Years:

Yes, if the organization's documented process includes how it notifies practitioners that the information is available on the Internet; and if the organization informs practitioners where the information is located. If all practitioners do not have access to the portal, the organizations process must include how it notifies these practitioners of patient engagement.

This applies to the following Programs and Years:

At least two prescriptions means that the patient had at least two pharmacy claims for a drug in the target class (this can be refills for the same drug). In the numerator, for a day to be covered, a patient must have a supply on hand of at least one drug in the class.

This applies to the following Programs and Years: