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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3.25.2020 COVID-19 If organizations choose to report their audited HEDIS 2019 hybrid rate, what data elements should they report in IDSS?

Organizations must report all IDSS data elements for any hybrid measure they report using their audited HEDIS 2019 hybrid rate.

HEDIS 2020

3.17.2020 COVID-19 Where do organizations note in IDSS that they are reporting their audited HEDIS 2019 hybrid rate?

Organizations cannot indicate that they are reporting their audited HEDIS 2019 hybrid rate in IDSS. Organizations must work with their auditors to ensure that these rates are reported correctly.

HEDIS 2020

3.17.2020 COVID-19 If organizations report a HEDIS 2020 measure using the Administrative Method, may they use their audited HEDIS 2019 rate instead?

No, measures being reported using the Administrative Method should be reported following the HEDIS 2020 reporting requirements. Only measures being reported using the Hybrid Methodology may report the higher of the HEDIS 2020 hybrid rate or the audited HEDIS 2019 hybrid rate.

HEDIS 2020

3.17.2020 COVID-19 May organizations enter data manually in IDSS, and will it trigger a warning?

Yes. Organizations may manually enter data in IDSS for HEDIS 2020; this will trigger a validation warning. Organizations should be able to explain to their auditor why the warning appeared.

HEDIS 2020

3.17.2020 COVID-19 Does NCQA have any guidance for MY 2020 reporting (June 15, 2021) and the impact COVID-19 will have on care delivery?

NCQA is actively working on a plan for MY 2020 reporting. We will announce our decisions as soon as they are finalized.

HEDIS 2020

3.16.2020 Plan All-Cause Readmissions When an index hospital stay is discharged to skilled nursing care facilities (SNF) which date is used for reporting the measure?

The discharge date from the index hospital stay should be used for reporting. The PCR measure assesses the number of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission. SNFs are considered to be nonacute inpatient settings. Therefore, when a member is transferred from an acute inpatient setting to a SNF, only the acute inpatient stay is assessed for reporting.

For example, a member has an acute inpatient stay February 1 – 5 and was discharged to a SNF February 6 – 9 and then transferred back to acute inpatient care February 10 – 14. There are two acute inpatient stays which are assessed for the PCR measure and count as two index hospital stays for the denominator (Stay 1 is February 1 – 5, Stay 2 is February 10 – 14), provided they meet all other measure criteria. Stay 2 is a readmission for Stay 1, provided it meets all numerator criteria because it occurs within 30 days of the discharge date for Stay 1. Stay 1 counts as an index hospital stay discharged to a SNF.

HEDIS 2020

3.16.2020 Plan All-Cause Readmissions Which risk weights are assigned to index hospital stays discharged to skilled nursing care when calculating expected readmission rates for the Medicare product line?

For the Medicare product line only, a “Skilled Nursing Care Stratification” was added to highlight the readmission rate among non-outlier Medicare beneficiaries who were discharged from the hospital to skilled nursing care. An index hospital stay discharged to skilled nursing care experienced by a non-outlier Medicare beneficiary is reported in several places and receives two sets of risk weights.

The tables in the PDF (https://www.ncqa.org/wp-content/uploads/2020/03/20200312_2020_PCR_Tables.pdf) illustrate assignment of risk weights for index hospital stays among two hypothetical Medicare beneficiaries meeting all other measure criteria (e.g. non-outlier, continuously enrolled, etc.). Index Hospital Stay #2 for member 1101 and Index Hospital Stays #1 and #2 for member 1202 are discharged to skilled nursing care.

Table 1 shows that these index stays are assigned the standard set of risk weights for reporting in Table PCR-A-1/2/3 and Table PCR-B-3. Do not assign the skilled nursing care risk weights for the stays in Table PCR-A-1/2/3 and Table PCR-B-3.

Table 2 shows that these same index stays are assigned the skilled nursing care risk weights for reporting the “Skilled Nursing Care Stratification” in Table PCR-C-3. Do not assign the standard set of risk weights for the stays in Table PCR-C-3.

Index hospital stays that are not discharged to skilled nursing do not need to be assigned the skilled nursing care risk weights and are not reported in the “Skilled Nursing Care Stratification” in Table PCR-C-3. Index Hospital Stays #1 and #3 for member 1101 are examples of events that do not need to be assigned the skilled nursing care risk weights and are not reported in the “Skilled Nursing Care Stratification”. The “Skilled Nursing Care Stratification” applies to the Medicare product line only and index hospital stays among other product lines do not use the skilled nursing care risk weights.

HEDIS 2020

3.15.2020 PHM 3, Element A, Factor 3: Practice transformation support Does reporting a physician’s designation or status as “integrated or advanced” practice in a web-based physician directory meet the requirement to support practice transformation?

No. Publicly reporting a practice’s designation or status does not constitute “active support.” Organizations may actively support transformation through financial incentives, learning collaboratives, MOC credits and other methods.

HP 2020

3.15.2020 Using Complaint Data to Supplement Surveys or Self-Reported Information In NET 2, Elements A–C, if an organization collects data using surveys or practitioner self-reported information, it must supplement the data with an analysis of complaints regarding access. Are organizations required to conduct a complete quantitative and qualitative analysis of complaint data?

No. Supplemental complaint data validates survey findings and self-reported information and assists in qualitative analysis of primary data. The organization is not required to conduct complete quantitative and qualitative analysis of supplemental data.

HP 2020

3.15.2020 PHM 3, Element B: Value Based Payment Arrangements Does NCQA require organizations to have more than one type (e.g., pay-for-performance, shared savings) of value-based payment arrangement per product line?

No. An organization meets the requirement if it has at least one VBP of any type per product line. Organizations may report more than one VBP arrangement per product line but are not required to do so.

HP 2020

3.15.2020 36-month Recredentialing time frame Does NCQA allow an organization to extend the 36-month recredentialing time frame if it failed to credential a practitioner on time?

No. Except as noted under “Related information: Extending the recredentialing cycle length,” where NCQA makes provisions for situations such as active duty military assignment and medical leave, the organization may not extend the 36-month recredentialing cycle. If the practitioner is not recredentialed within 36 months, the file will be scored down. There is no grace period for recredentialing.
If an organization missed the recredentialing deadline and intends to keep the practitioner in the network, files must be processed as follows:

If the organization can complete the credentialing process within 30 days of the original due date, it may recredential the practitioner (e.g., the organization need not verify credentials required only at initial credentialing). The organization must complete the process and make the credentialing decision within 30 days of the original credentialing due date.
If the organization cannot complete the credentialing process within 30 calendar days of the original recredentialing due date, it must take the practitioner through the initial credentialing process.

MBHO 2019

3.15.2020 Clarifying HPA 2020 Scoring with File Review Scoring Question Please explain “PARTIALLY MET” for scoring that reads “High (90-100%) or medium (60-89%) on file review for X factors” in file review elements (e.g., PHM 5, Element D)?

Interpret that text to mean any combination of high and medium other than the scoring thresholds specified for “MET.”
For example, an organization must earn “high” on 7 factors to score MET on PHM 5, Element D; therefore, to score “PARTIALLY MET” for that element, it may earn “high” on 0–6 factors and “medium” on the remaining factors.

HP 2020