No. The internal appeal notification must be sent to the member.
The UM 9, Element D stem incorrectly states that both the member and the treating practitioner must be notified. This will be corrected in November’s Policy Updates.
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9.15.2021 Notification of Internal Appeal to Member or Treating Practitioner Must an internal appeal notification be sent to both the member and the treating practitioner?
9.15.2021 Use of HIP Delegate and Virtual-Only Practitioner If an organization adds virtual-only practitioners to its network and utilizes an NCQA-Certified Health Information Product (HIP) delegate for directory requirements in HIP 4, must the delegate indicate “virtual only” on the directory?
Yes. The NCQA-Certified HIP delegate must indicate “virtual only” in the directory if there is not a physical office, to meet HIP 4. If the organization manages any part of the directory, “virtual only” must be indicated where applicable.
This applies to the following Programs and Years:
HIP 20169.15.2021 Acute Hospital Utilization, Emergency Department Utilization and Hospitalization for Potentially Preventable Complications May covariance values be rounded before using them in the variance calculation?
No. Do not round covariance values for use in variance calculations. Member-level PPD and PUCD should be unrounded in covariance and variance calculations, although truncation to 10 decimal points is applied, per the previous step. NCQA intends to evaluate truncation and rounding logic throughout intermediate calculations to ensure consistency and reduce potential bias in a future publication release.
This applies to the following Programs and Years:
HEDIS MY 2020, 20219.15.2021 PCS Questions Do answers from the Policy Clarification Support system have an expiration date?
We recommend that organizations not use PCS responses that are over 3 years old. If a question relates directly to a measure specification or a general guideline that was revised from a previous measurement year, we recommend resubmitting the question.
This applies to the following Programs and Years:
HEDIS MY 20229.15.2021 Acute Hospital Utilization, Emergency Department Utilization and Hospitalization for Potentially Preventable Complications May covariance values be rounded before using them in the variance calculation?
No. Do not round covariance values for use in variance calculations. Member-level PPD and PUCD should be unrounded in covariance and variance calculations, although truncation to 10 decimal points is applied, per the previous step. NCQA intends to evaluate truncation and rounding logic throughout intermediate calculations to ensure consistency and reduce potential bias in a future publication release.
This applies to the following Programs and Years:
HEDIS MY 20229.15.2021 Guidelines for Calculations and Sampling: Hybrid Method How should the eligible population be reported for hybrid measures if there are optional or required exclusions?
The eligible population for hybrid measures should be reported before the optional exclusions and after the required exclusions for all three hybrid method approaches (refer to Appendix 4 in HEDIS Volume 2). For example, if the eligible population is 100 members and 10 members met optional exclusion criteria, then the reported eligible population value must still be 100.
This applies to the following Programs and Years:
HEDIS MY 20229.15.2021 Acute Hospital Utilization, Emergency Department Utilization and Hospitalization for Potentially Preventable Complications When should rounding occur for variance calculations?
The variance should not be rounded until the final step in the calculation. The final variance calculation for reporting should be rounded to four decimal places using the .5 rule. For example, the PPD and PUCD values are truncated to 10 decimal places, multiplied together at the member level and summed across members for the total. Round the total sum to four decimal places.
This applies to the following Programs and Years:
HEDIS MY 20229.15.2021 PCS Questions Do answers from the Policy Clarification Support system have an expiration date?
We recommend that organizations not use PCS responses that are over 3 years old. If a question relates directly to a measure specification or a general guideline that was revised from a previous measurement year, we recommend resubmitting the question.
This applies to the following Programs and Years:
HEDIS MY 2022, 20217.15.2021 Use of Mail Service Organizations for Distribution Requirements Is it considered delegation if an organization uses a mail service organization to meet distribution requirements?
NCQA considers it to be delegation if the organization uses another organization, including a mail service organization, to perform any function not listed in the “Vendor” section of Appendix 3.
NCQA considers it to be a vendor relationship if the organization uses another organization (e.g., a mail service organization) to perform functions evaluated by the elements or element components listed in the "Vendor" section of Appendix 3.
This applies to the following Programs and Years:
MBHO 2021|UM-CR-PN 20217.15.2021 Colorectal Cancer Screening (COL) On May 18, 2021 the U.S. Preventive Services Task Force (USPSTF) updated the colorectal cancer screening recommendations to screen for colorectal cancer in adults aged 45 to 49 years. Will NCQA update the COL measure to coincide with the USPSTF recommendations that lower the screening age to 45? If yes, what HEDIS year can we expect this change to be reflected in the measure specs?
NCQA is aware of updates to the US Preventive Services Task Force (USPSTF) guidelines for colorectal cancer screening. Given these updates, NCQA will evaluate potential changes to the HEDIS Colorectal Cancer Screening (COL) measure through input from our clinical and technical measurement advisory panels, the Committee on Performance Measurement and public comment. Any potential changes to the measure resulting from this evaluation would be included in the HEDIS MY 2022 Technical Update at the earliest.
This applies to the following Programs and Years:
HEDIS MY 20217.15.2021 Use of Mail Service Organizations for Distribution Requirements Is it considered delegation if an organization uses a mail service organization to meet distribution requirements?
NCQA considers it to be delegation if the organization uses another organization, including a mail service organization, to perform any function not listed in the “Vendor” section of Appendix 2.
NCQA considers it to be a vendor relationship if the organization uses another organization (e.g., a mail service organization) to perform functions evaluated by the elements or element components listed in the "Vendor" section of Appendix 2.
This applies to the following Programs and Years:
HP 20217.15.2021 Virtual-Only Practitioners If an organization wants to add virtual-only practitioners to its network for services such as behavioral health, does that affect NET 5 and CR 1?
Yes. If an organization adds virtual-only practitioners to its network, the provider directory must indicate that such practitioners are virtual only (i.e., in lieu of a physical office location) to meet NET 5, Element A. Virtual-only practitioners must also be fully credentialed, per requirements in CR 1, Element A.
