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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No. The medical record review process for the hybrid data collection methodology requires that information be abstracted from the medical record. CCDs are not the same as the medical record; this includes CCDs received from health information exchanges. Note that because electronically exchanged CCDs may be used as supplemental data, they are subject to supplemental data requirements.
No. Evidence that the PCP or ongoing care provider reviewed the admission/discharge information is not required for these indicators. If the required information is filed in the outpatient medical record or shared EMR (accessible to the PCP or ongoing care provider) during the required time frame, this alone meets criteria.
No. Admission/discharge notifications in the ADT alone do not meet criteria (even if the provider has access to the ADT) because ADTs are not considered the legal medical record.
Criteria are met if the provider documents ADT notifications in the appropriate outpatient medical record or shared EMR (accessible to the PCP or ongoing care provider) during the time frame specified in the measure.
NCQA currently does not rate Exchange plans for Health Plan Ratings/Health Plan Accreditation (HPR/HPA). This is primarily because CMS has their own Quality Rating System (QRS), and NCQA has to receive special permission from CMS to use the data for our Accreditation program. NCQA is actively participating in these discussions, and any changes to this policy will be communicated to all organizations in a timely manner.
NCQA defines “state coverage” as the states where a plan is licensed to operate. Plans that submit HEDIS/CAHPS data provide this information each year during the HOQ process. If plans do not submit these data, NCQA uses state licensing and membership data provided for Accreditation or gathered from external sources.
We anticipate that PCV20 will be added to the CIS value sets in the HEDIS MY 2024 Technical Update, scheduled for release on April 1, 2024.
Although the PCV20 vaccine is not included in the measure for MY 2023, NCQA does not anticipate this will impact performance. The measure denominator only includes children who were at least 18 months old and expected to have already completed the pneumococcal series by June 2023 (the month when ACIP recommended PCV20).
If an organization delegates more than 50% of primary source verifications and one or more of its delegates loses Accreditation/Certification status, NCQA considers this a Reportable Event. The organization must notify NCQA (through My.NCQA.org) within 30 calendar days.
Typically, no as health plan staff are not practicing practitioners within the health plan's network. The intent of collaboration requirements are for organizations to demonstrate collaboration between their behavioral healthcare delivery system (network practitioners) and medical care delivery system (network practitioners).
Note: Demonstrating collaboration with an MBHO is acceptable for the collaboration with “behavioral healthcare practitioners” component of the requirement.
This means that the information is not all medical jargon. So instead of the care plan stating, “1 PO BID”, the practice may say “take one by mouth two times a day.” Instead of hardcoded complex diagnosis names and codes, write the diagnosis in common language. For example, instead of only providing the diagnosis of “dyspnea,” use “shortness of breath.”
The intent is to ensure that the patient understands his/her condition(s), goals, and plans to follow to improve their health.
The document should not simply be a hardcoded paper that auto-populates structured fields from the EHR into the document. It should contain language showing that the patient provided input and understands the plan. NCQA is not prescriptive on specific verbiage that must be in the care plan.
The intent of CM 04 is to give the patient ownership and the power to improve their health outcomes. Engaging the patient in the development of their care plan can result in greater success and adherence to treatment goals.
