Yes. Organizations may use SAM.gov to verify Medicare and Medicaid sanctions for CR 3, Element B, factor 2 and CR 5, Element A, factor 1.
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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11.15.2023 Using SAM.gov for Medicare/Medicaid Sanctions Is SAM.gov an acceptable source for verifying Medicare and Medicaid sanctions?
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
Members Recommended for Routine Cervical Cancer Screening The Cervical Cancer Screening (CCS and CCS-E) measures include the following criteria to identify members recommended for routine cervical cancer screening:
• Administrative Gender of Female (AdministrativeGender code F) any time in the member’s history.
• Sex Assigned at Birth (LOINC code 76689-9) of Female (LOINC code LA3-6) any time in the member’s history.
• Sex Parameter for Clinical Use of Female (SexParameterForClinicalUse code Female-typical) during the measurement year.
What data sources can be used to identify these members?
When reporting CCS-E, all three methods may be used, using any data source. When reporting CCS, use only administrative data (Administrative Gender of Female [AdministrativeGender code F] any time in the member’s history) to determine members recommended for routine cervical cancer screening.
Where supplemental data may be used for CCS remains the same for MY 2024. Supplemental data may not be used for denominator criteria, except in required exclusions.
This applies to the following Programs and Years:
HEDIS MY 202411.15.2023 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 202411.15.2023 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?
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 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 CAQH Application: Illegal drug use question Does the CAQH application question about lack of current illegal drug use meet the intent of NCQA’s requirement in CR 3, Element C, factor 2?
Yes, the following CAQH question meets the intent of the requirement in CR 3, Element C, 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 CR 3, Element C, 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:
HP 2023, 2024|MBHO 2023|UM-CR-PN 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).
This applies to the following Programs and Years:
HEA 2023, 202410.16.2023 Credentialing application question about present illegal drug use (CVO) Would the following question on a credentialing application meet the intent of CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2? “Are you currently using illegal drugs that could affect your ability to practice medicine?”
Yes. NCQA uses language in the Explanation that organizations may use more general or extensive language to query practitioners about impairment.
Note: This question was previously posted on August 15, 2023 and reevaluated by NCQA. This FAQ answer replaces the previously posted response.
This applies to the following Programs and Years:
CVO 202210.16.2023 Credentialing application question about present illegal drug use Would the following question on a credentialing application meet the intent of CR 3, Element C, factor 2? “Are you currently using illegal drugs that could affect your ability to practice medicine?”
Yes. NCQA uses language in the Explanation that organizations may use more general or extensive language to query practitioners about impairment.
Note: This question was previously posted on August 15, 2023 and reevaluated by NCQA. This FAQ answer replaces the previously posted response.
