FAQ Directory

Deduplicate denominator episodes to one per day. Two eligible SUD encounters on the same date of service count as one denominator episode.  

This applies to the following Programs and Years:

No. There is no minimum denominator requirement. A sample of 30 (or more, because this increases the reliability of the sample) is expected to ensure statistical soundness, but there may be cases where it may be appropriate for the denominator to be <30. NCQA requests practices enter an explanation in the Notes from the Organization section in QPASS in this case.

If a practice reports a denominator <30 without a note, the evaluator may contact the practice to confirm data accuracy and to understand the data. The evaluation will be returned to the practice so they can enter an explanation in the Notes from the Organization section for the cited criteria.

This applies to the following Programs and Years:

It is to ensure patient safety and routine implementation of medical home activities. Depending on the population served and/or the reporting period, a small denominator is unexpected and may indicate issues (e.g., with data, documentation, implementation). Providing additional information allows the practice to explain—beyond the numbers—when performance is outside the expected range.

This applies to the following Programs and Years:

Yes. The RAND should be “0.58” for LTSS-SCP, LTSS-CAU and LTSS-CPU for HEDIS LTSS MY 2022 reporting.

This applies to the following Programs and Years:

For Maryland practitioners credentialed between December 2021 and February 2022, NCQA will not penalize organizations on inability to verify licensure due to the MDH network security incident. NCQA accepts the MDH’s grace period on licensure expirations and accepts temporary licenses issued by the MDH and will consider them current and valid. Organizations should adhere to guidance provided by MDH and document the guidance in the affected practitioners’ credentialing files.

This applies to the following Programs and Years:

NCQA continues to monitor the impact of COVID on communities and at this time has no plans to modify data collection methods and reporting deadlines.

This applies to the following Programs and Years:

For measures with stratifications, use the total rate when reducing sample sizes. For measures with multiple indicators and stratifications, use the lowest total rate across indicators when reducing sample sizes.

This applies to the following Programs and Years:

Administrative data, codes in the Absence of Cervix Diagnosis Value Set (e.g., ICD-10-CM Diagnosis code Q51.5 [agenesis and aplasia of cervix]) may be used to exclude transgender members from the measure. If the medical record documents that the member was born male (e.g., transgender male to female), this is evidence that the member does not have a cervix, meets optional exclusion criteria and may be removed from the measure. Medical record documentation of cervical agenesis or clinical synonyms (e.g., evidence a patient was born without a cervix) may also be used to exclude these members. These members should remain in the measure if the organization is unable to find the appropriate documentation.

This applies to the following Programs and Years:

Yes. NCQA has decided to allow sampling for organizations that use auditing as the method for monitoring in UM 11, Elements A – D and CR 1, Elements C and D. Organizations must use the “5% or 50 files” audit method: Organizations randomly select 5% or 50 files, whichever is less, from each applicable file type, to review against the requirements: 

• Credentialing and recredentialing. (5% or 50 files total)  
  • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample. 
• UM denials (5% or 50 files). 
• UM appeals (5% or 50 files). 

For each applicable file type noted above, the organization must determine the sample size of 5% or 50 files (whichever is less) based on all files in the file universe. The file universe includes all files with or without modifications. The sample that will be audited must include only files with modifications (i.e., modifications that meet and do not meet the organization’s policies and procedures). NCQA does not specify how the organization selects the sample once the sample size is determined using the entire file universe. It may select the sample of modified files from the universe or, if the organization can identify files with modifications, it may randomly select the sample that will be audited from only the modified files.
The organization’s analysis report must include the number or percentage of files that do not meet the organization’s policies and procedures.
Example for UM denials:

• An organization’s UM denial file universe contains 800 files with and without modifications. Therefore, the minimum required sample for review is 40 files (5% of 800) which is less than 50 files. The organization must randomly select the 40 files for review from the total universe of 800 files or from only files with modifications (if the organization’s system has the capability to identify files with modifications). All 40 files must have a modification and are reviewed against the organization’s policies and procedures to identify noncompliant modifications.

Note: The underlined text is an update to the FAQ posted on January 15, 2022.

This applies to the following Programs and Years:

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

• 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
  • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample.
• The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

This applies to the following Programs and Years:

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

• 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
• The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

This applies to the following Programs and Years:

Yes. NCQA has decided to allow sampling for organizations that use auditing as the method for monitoring in UM 12, Elements A – D and CR 1, Elements C and D. Organizations must use the “5% or 50 files” audit method: Organizations randomly select 5% or 50 files, whichever is less, from each applicable file type, to review against the requirements: 

• Credentialing and recredentialing. (5% or 50 files total)  
  • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample. 
• UM denials (5% or 50 files). 
• UM appeals (5% or 50 files). 

For each applicable file type noted above, the organization must determine the sample size of 5% or 50 files (whichever is less) based on all files in the file universe. The file universe includes all files with or without modifications. The sample that will be audited must include only files with modifications (i.e., modifications that meet and do not meet the organization’s policies and procedures). NCQA does not specify how the organization selects the sample once the sample size is determined using the entire file universe. It may select the sample of modified files from the universe or, if the organization can identify files with modifications, it may randomly select the sample that will be audited from only the modified files.

The organization’s analysis report must include the number or percentage of files that do not meet the organization’s policies and procedures.
Example for UM denials:

• An organization’s UM denial file universe contains 800 files with and without modifications. Therefore, the minimum required sample for review is 40 files (5% of 800) which is less than 50 files. The organization must randomly select the 40 files for review from the total universe of 800 files or from only files with modifications (if the organization’s system has the capability to identify files with modifications). All 40 files must have a modification and are reviewed against the organization’s policies and procedures to identify noncompliant modifications.

Note: The underlined text is an update to the FAQ posted on January 15, 2022.

This applies to the following Programs and Years: