No. Notice of Medicare Non-Coverage (NOMNC) denial files are out of NCQA’s scope of review and should be excluded from the UM file universe.
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11.15.2023 Notice of Medicare Non-Coverage (NOMNC) Denials For the UM file review universe, should plans include concurrent denials for Medicare members that involve issuance of a Notice of Medicare Non-Coverage (NOMNC) document?
11.15.2023 CVO: Using SAM.gov for Medicare/Medicaid Sanctions Is SAM.gov an acceptable source for verifying Medicare and Medicaid sanctions?
11.15.2023 Excluding Laboratory Claims (Claims with POS Code 81) Will instructions to exclude laboratory claims (claims with POS code 81) be added to additional measures and value sets in the Technical Update memo?
Yes. We anticipate the laboratory claim exclusion will be added to the following measures and value sets in the Technical Update memo:
AMR: Step 2 of the event/diagnosis (Asthma Value Set)
GSD: Numerators (HbA1c Test Result or Finding Value Set)
EED: Event/diagnosis (Diabetes Value Set)
OMW: Step 2 of the event/diagnosis (Fractures Value Set)
SSD: Numerator (HbA1c Test Result or Finding Value Set)
SMD: Numerator (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
SMC: Numerator (LDL-C Test Result or Finding Value Set)
IET: Step 2 of the event/diagnosis (Alcohol Abuse and Dependence Value Set; Opioid Abuse and Dependence Value Set; Other Drug Abuse and Dependence Value Set)
APM-E: Numerators (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
DSF-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Depression Value Set)
DMS-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
DRR-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
ASF-E: Exclusions 1 (Alcohol Use Disorder Value Set; Dementia Value Set)
This applies to the following Programs and Years:
HEDIS MY 202410.16.2023 Palliative Care Timeframe for Risk of Continued Opioid Use (COU) The time frame for palliative care (bullets 2 and 3 under “Required exclusions”) in the COU measure states to identify palliative care during the measurement period. Is this correct?
10.16.2023 Race and Ethnicity Stratification for Childhood Immunization Status (CIS) and Cervical Cancer Screening (CCS) Race and ethnicity stratification criteria are listed for CIS-E but not for CIS, and for CCS-E but not for CCS. Is this intentional?
Yes. Race and ethnicity stratification is not required for traditional reporting of CIS and CCS. The race and ethnicity stratifications are reported when using the Electronic Clinical Data Systems reporting standard for CIS-E and CCS-E.
This applies to the following Programs and Years:
HEDIS MY 202410.16.2023 Explanation of Benefit (EOB) The digital measure packages for MY 2024 include “Explanation of Benefit” (EOB) criteria. What does that mean?
Although HEDIS digital measure logic references “Explanation of Benefit (EOB),” this is not referenced as a data source in HEDIS Volume 2. In FHIR, the EOB resource represents claims that have been adjudicated, and includes data elements from both Claim and ClaimResponse. The digital logic was written to include the Claim/ClaimResponse resource for claims that are still processing; the ExplanationOfBenefit resource is for claims that are adjudicated.
This applies to the following Programs and Years:
HEDIS MY 202410.16.2023 UM 12, Element C, factor 2 for mail service delegates Can organizations submit a mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit for UM 12, Element C, factor 2?
10.16.2023 Updated: MBHO: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?
Yes. Using UM 12: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 12, Element A: Delegation Agreement
- Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution
- Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance.
- Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
- Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.
UM 12, Element C: Review of the UM Program
- Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates
- Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
- Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit. This must be specified in the delegation agreement.
Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.
This applies to the following Programs and Years:
MBHO 2022, 202310.16.2023 CAQH Application: Illegal drug use question (CVO) Does the CAQH application question about lack of current illegal drug use meet the intent of NCQA’s requirement in CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2?
Yes, the following CAQH question meets the intent of the requirement in CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2:
Are you currently engaged in the illegal use of drugs?* ("Currently" means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.)"
CAQH provides additional information regarding what "currently" means that aligns with language in the explanation of CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2 that the organization may use more general or extensive language to query practitioners about impairment.
This applies to the following Programs and Years:
CVO 202210.16.2023 UM 13, Element C, factor 2 for mail service delegates Can organizations submit a mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit for UM 13, Element C, factor 2?
10.16.2023 Updated: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?
Yes. Using UM 13: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 13, Element A: Delegation Agreement
- Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution (e.g., UM 11, Element B (annual updates for pharmaceutical restrictions/preferences).
- Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance, if applicable.
- Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
- Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.
UM 13, Element C: Review of the UM Program:
- Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates.
- Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
- Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit. This must be specified in the delegation agreement.
Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.
This applies to the following Programs and Years:
HP 2022, 2023, 2024|UM-CR-PN 2022, 202310.16.2023 Use of organization-level documentation for Health Equity Accreditation If an entity seeking Health Equity Accreditation is part of a larger organization (e.g., corporate parent) that is not seeking Accreditation, can the entity use documentation at the larger organization level to meet Accreditation requirements?
It is acceptable to use larger organization-level documented processes or policies and procedures to meet applicable requirements (e.g., for HE 1, Element A, factor 1) if the entity seeking Accreditation demonstrates that it follows the same processes. However, the entity seeking Accreditation must provide documentation that pertains specifically to its organization for requirements that require action or implementation of such processes (e.g., for HE 1, Element A, factors 2 and 3).