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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11.15.2018 Hospitalization for Potentially Preventable Complications On page 458 under step 5 there are instructions for how the number of members in the eligible population data element is reported in IDSS. It states, “Enter these values in the reporting table (HPC-A-3).” However, in that table, the column titled “Members in the Eligible Population” is shaded gray, indicating that it is calculated by IDSS. Is the data element reported by the organization, or calculated by IDSS?

“Number of Members in the Eligible Population” is calculated by IDSS. The shading in the data element table is correct. The step 5 instructions are incorrect and should indicate that this is a calculated field. 

HEDIS 2019

11.15.2018 All ECDS Measures What is Source of Payment (SOP) Typology?

The Source of Payment Typology was developed to create a standard for classifying payer type. In measure specifications, it will enhance identification of specific payer identity in clinical data used for NCQA reporting.  

Modeled loosely after the ICD typology for classifying medical conditions, the SOP Typology identifies broad payer categories (step 2) with related subcategories that are more specific to a product (steps 3 and 4). The first digit of each code represents the organization providing the funds for care; subsequent digits provide more-specific information about the mechanism used to provide funds. This format provides the flexibility to either use payer codes at a highly detailed level or to roll up codes to broader categories for comparative analysis across payers and locations.

SOP Typology can be used by anyone to code the payment data source. Use of the payer classification may require a crosswalk of previous code lists to the new hierarchical payer typology.  
Example steps for plan classification using SOP Typology: 

1. Plan needing typology classification: Harvard Pilgrim Health  
2. Determine main category for first digit: 5 (Commercial) 
3. Determine subcategory for second digit: 1 (Managed Care Private)
4. Determine subcategory breakdown for third digit: 2 (PPO) 
5. Assign final SOP classification code: 511 (Commercial Managed Care-HMO)  

HEDIS 2019

10.15.2018 Standardized Healthcare-Associated Infection Ration The HEDIS® 2019 Volume 2 Technical Specifications Update announced the suspension of the Standardized Healthcare-Associated Infection Ration (HAI) measure for all product lines. This change causes a discrepancy between the CMS Reporting Memo and HEDIS 2019 Volume 2 Technical Specifications. Will CMS clarify what must be reported for HEDIS 2019 for Medicare?

Yes. CMS released a clarification, through Health Plan Management System (HPMS) on October 12, 2018, that HAI has been suspended and is not required for HEDIS 2019 reporting. If you have additional questions about CMS requirements, contact HEDISquestions@cms.hhs.gov.

HEDIS 2019

10.15.2018 Total Membership How should organizations handle dually enrolled members for the Total Membership (TLM) measure? Should organizations follow the "total unduplicated membership" rule, or should they follow General Guideline 15 and count the member twice (where applicable)?

Organizations should refer to General Guideline 15 in the HEDIS 2019 Volume 2 publication for guidance on reporting members with dual enrollment for the TLM measure. However, when General Guideline 15 allows members to be included in more than one product line deduplicate and count members only once in the measure as follows:

 -Report members with dual Medicaid/Medicare enrollment in the Medicare product line.       

 –For other dual enrolled members report the members in the primary product line.

HEDIS 2019

10.15.2018 80% must-pass threshold for UM elements Because NCQA raised the UM must-pass threshold from 50% to 80%, will NCQA create an 80% scoring option for requirements without such a scoring option?

No. To keep scoring simple, NCQA set a threshold of 80% or higher for all UM must-pass elements, rather than setting a specific threshold for each element based on its scoring options. If an element does not have an 80% option, the “or higher” applies. Keep in mind that an organization may miss the requirements for a few files and still score 100% on the element. For additional information on file review scoring, refer to the scoring table in each element or to the file review worksheet in the Interactive Review Tool (IRT).

HP 2019

10.15.2018 Immunizations for Adolescents Are issuers required to report Combo 1 for the Quality Ratings System in the Immunizations for Adolescents (IMA) measure?

No. HEDIS for QRS requires collection of only Combination 2 and related antigens. Change the reference in the Description from “two combination rates” to “one combination rate.” In the Data Elements Table, change “Each of the 5 rates” to “Each of the 4 rates.”

Exchange 2019

10.15.2018 Plan All-Cause Readmissions In General Guideline 15: Members With Dual Enrollment, the Medicare-Medicaid (MMP) subhead indicates that these members must be in both the Medicaid and Medicare HEDIS reports. Does this apply to Plan All-Cause Readmissions (PCR)?

No. For PCR, MMP members are removed from Medicaid reporting and are included in only Medicare reporting.

HEDIS 2019

10.15.2018 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis Should the “Numerator events by supplemental data” row be removed from the Data Elements Table in the Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB) measure?

Yes. Remove the “Numerator events by supplemental data” row in the Data Elements Table.

Exchange 2019

10.15.2018 Use of Imaging Studies for Low Back Pain Should the “Numerator events by supplemental data” row be removed from the Data Elements Table in the Use of Imaging Studies for Low Back Pain (LBP) measure?

Yes. Remove the “Numerator events by supplemental data” row in the Data Elements Table.

Exchange 2019

10.15.2018 Required Exclusions Are members who are excluded because of hospice, advanced illness, frailty, Institutional SNP (I-SNP) or living long-term in an institution (LTI) included in the “Number of required exclusions” data element?

No. Only members who meet the criteria in the section of the measure labeled “Required exclusions” are included when reporting the “Number of required exclusions” data element.

HEDIS 2019

10.15.2018 Rules for Allowable Adjustments The General Guidelines in the Rules for Allowable Adjustments states, “use the separate HEDIS Adjustments VSD to calculate measure rates stemming from adjusted measure specification.” Does this mean that ONLY the HEDIS Adjustments VSD must be used?

No. The Allowable Adjustments VSD does not contain the standard HEDIS value sets; standard HEDIS value sets are in the HEDIS 2019 Volume 2 VSD. The Allowable Adjustments VSD includes only SNOMED and LOINC codes that are not in the Volume 2 VSD. Organizations collecting data using the rules for allowable adjustments can elect (but are not required) to use the value sets in the Allowable Adjustments VSD.

HEDIS 2019

10.15.2018 Follow-Up After ED visit for People With Multiple High-Risk Chronic Conditions In Step 2 (Exclusions), ED visits followed by admission to an inpatient care setting on the date of the visit or within 7 days after the visit are excluded. Should ED visits that result in an inpatient stay (when the ED date of service occurs any time during the admission [admission date through discharge date]) also be excluded?

Yes. Exclude ED visits that result in an inpatient stay.

HEDIS 2019