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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12.14.2018 Appendix 3: PCP Definition May rural health centers be mapped to the PCP definition in Appendix 3 of Volume 2, similar to how Federally Qualified Heath Centers are handled?

No. Rural Health Clinics are not addressed in the updated PCP definition in Volume 2. All providers billing under the Rural Clinic facility codes must meet the definition of “PCP” in Appendix 3 in order to be included in the PCP-based HEDIS measures.

HEDIS 2019

12.14.2018 Hospitalization for Potentially Preventable Complications On page 453 of the HPC measure, the language for the first sentence in step 3 under “Chronic ACSC” is different than the language for the first sentence in step 3 under “Acute ACSC”. Is the difference in the language intentional?

No, the difference in the language is not intentional and the reference to “on the discharge claim” was unintentionally excluded. Step 3 for Acute ACSC should contain the same language as step 3 for chronic ACSC. In step 3 for ACSC, for the remaining acute inpatient and observation stay discharges, organizations should identify discharges with specified criteria on the discharge.

HEDIS 2019

12.14.2018 ECDS May plans use administrative data (e.g., claims, enrollment) for ECDS reporting?

Yes. Plans may use administrative data to report HEDIS ECDS measures. Administrative data are a relevant data source and are one of four categories of data for ECDS reporting. If a plan’s administrative data files contain all the information it needs for a measure, it does not need additional data.

HEDIS 2019

12.14.2018 SES Guidelines* To calculate a member’s SES stratification, the instructions say to use the Monthly Membership Detail Data Files (MMDDF) for the measurement year to assess the member’s LIS, DE payment status. We find that in some months, members have multiple rows of data in the MMDDF, which represent adjustments for previous months. What should we do in this situation; is there a better file to use for determining SES?

Because the SES assessment is new and requires files not normally used for NCQA’s measure calculations, we have explored options for reporting members with these scenarios, and we think there are options for these data.
NOTE: NCQA’s Certification program tests one record per member based on the MMDDF.

  • Option 1: If you are using MMDDF and one month has multiple rows for a member with different values in one row or more, sum the values and use the result to compare to the other 3 months. Remember that what is important is whether the number is > 0 or it is < or = 0. See this example:

 

Member RunDate LisPremiumSubsidy
1 2018 10 12 0000.00
1 2018 10 12 0035.50
1 2018 11 08 0035.50
1 2018 11 08 -0035.50
1 2018 11 08 0035.50
1 2018 12 08 0035.50

This member is counted as LIS eligible: the sum of October = 35.50, the sum of November = 35.5, and December = 35.50 (all months are >0).

Member LowIncomePeriodStartDate LowIncomePeriodEndDate LipsPercentage PremiumLisAmount ContractYear
1 2016 09 01 2016 12 31 100 36.00 2016
1 2017 01 01 2017 12 31 100 36.00 2017
1 2018 01 01   100 35.50 2018

 
This file clearly shows that the member was LIS eligible for the HEDIS 2019 measurement year (calendar year 2018). If you have access to this file, it may be the easiest, most accurate data to use.
 
NOTES:

  1. If the LowIncomePeriodEndDate is blank, the member is still eligible.
  2. Plans should use a copy of this file from December 2018 or later.

 
*This same FAQ was posted on November 15, 2018 but was updated in the December 2018 FAQ posting. In the above “NOTES” section, it used to read that plans should use a copy of the file from January 2019 or later. This date was corrected to December 2018 or later.
 

HEDIS 2019

12.14.2018 ECDS Who is considered part of the care team?

Any practitioner who provides care to or makes care decisions for or about a member’s care is part of the care team. Please note, if a measure has a practitioner type requirement the services required by the measure must still be performed by the appropriate practitioner type. However, the care team requirement for the data to qualify for ECDS reporting is not restricted by the practitioner type requirement.

HEDIS 2019

11.15.2018 SES Guidelines To calculate a member’s SES stratification, the instructions say to evaluate whether the member’s LIS values (item 35) are the same or different in the last 3 months of continuous enrollment (CE). How do you determine if a value is the same or different?

A value is different if it is either < or = 0 OR > 0. For the last 3 months of the CE period:

  • Count the member as receiving an LIS payment if 2 of the last 3 months are >0, even if the values are different.
           Example:
           October       LIS = 35
           November   LIS = 40
           December   LIS = -35
  • Count the member as NOT receiving an LIS payment if 2 of the last 3 months are < or = 0, even if the values are different.
          Example:
          October       LIS = 0
          November   LIS = -35
          December   LIS = 35

 

HEDIS 2019

11.15.2018 Transitions of Care When reporting Receipt of Discharge Information, if the PCP or ongoing care provider is the discharging provider, are the requirements the same to meet numerator criteria?

Yes. When the PCP or ongoing care provider is the discharging provider, they must document the required discharge information specified in the measure. This must be done in the patient's outpatient medical record on the day of discharge or on the following day.

HEDIS 2019

11.15.2018 Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis If a member is included in the ART measure due to a rule-out diagnosis, may the member be removed from the denominator based on medical record documentation indicating an incorrect diagnosis of rheumatoid arthritis?

No. Members may not be removed from HEDIS measures due to billing errors. HEDIS does allow removal of “valid data errors” if they can be substantiated through medical record documentation; however, this applies only to hybrid measures. Because the ART measure is administrative only, the use of valid data errors is not permitted, nor may supplemental be used as a substitute for claims data (to correct billing errors) or to identify valid data errors.

HEDIS 2019

11.15.2018 Transitions of Care When reporting the Patient Engagement After Inpatient Discharge indicator, if the member is unable to communicate with the provider, does an interaction between the member’s caregiver and the provider meet criteria?

Yes, if the interaction meets criteria based on the measure specifications. The caregiver is not required to be designated as the patient’s legal guardian for the interaction to count toward the measure.  

HEDIS 2019

11.15.2018 Appeals covered in QI 6 What types of appeals are included in QI 6, coverage appeals (e.g., in UM 8–UM 9) or noncoverage appeals (e.g., in RR 2)?

QI 6 requires organizations to collect data from all sources of member complaints and appeals, including UM coverage appeals addressed in UM 8–UM 9 and noncoverage appeals addressed in RR 2.
Note: Data collected and analyzed before February 15, 2019, will be accepted as meeting the requirement even if not all types of appeals are included. Data collected and analyzed on or after this date must comply with the requirement stated in the FAQ.
If your organization collected and analyzed data before February 15, 2019, and interpreted the requirement as applying to only one type of appeal, notify the surveyor at the start of the survey so the misinterpretation does not affect scoring.
 

MBHO 2018

11.15.2018 General Guidelines Do standard supplemental data files need to contain all data elements required by the hybrid specification, regardless of the method used by the plan to report the measure?

Yes. As stated in General Guideline 30, both standard and nonstandard supplemental data files must contain all data elements required by the hybrid specification, regardless of the reporting method used (administrative or hybrid). However, for HEDIS 2019, NCQA makes an exception for only standard supplemental data files and for only the Adult BMI Assessment (ABA) and Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) measures.

Because the values (height, weight) used to calculate BMI are often stored in EMRs and not included in data extracts, NCQA does not want to penalize plans for not having these data elements in their data files. Auditors may approve standard supplemental data files that include only the date and the BMI value or percentile.

For the WCC nutrition and physical activity counseling indicators, a date of service and an applicable code from the VSD counts as compliant.

NCQA is evaluating the standard supplemental data requirement for all other hybrid measures for HEDIS 2020.

HEDIS 2019

11.15.2018 Transitions of Care When reporting Notification of Inpatient Admission and Receipt of Discharge Information indicators using an integrated EMR system, is a “received date” required in the EMR if the information was in the shared EMR on the day of admission/discharge or on the following day?

No. With a shared EMR, evidence that the information was filed/accessible by the PCP or ongoing care provider on the day of admission/discharge or the following day meets criteria for Notification of Inpatient Admission and Receipt of Discharge Information indicators. The organization is not required to find additional notation of a “received date” if it is evident that the information was in the shared EMR on the day of admission/discharge or the following day.

HEDIS 2019