FAQ Directory

Categorize members in the “Any Services” category based on their age as of the first eligible encounter in any service category.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

The intent of excluding ED/observation visits that result in an inpatient stay is to not double count events. For example, an ED visit with a principal mental health diagnosis that resulted in an inpatient stay for a principal diagnosis of mental health is reported only once in the “Inpatient Stay” category. An ED visit with a principal mental health diagnosis that resulted in an inpatient stay with a principal diagnosis for something other than mental health (e.g., heart attack) is reported only once in the “ED” category.

This applies to the following Programs and Years:

No. Plans do not need to be able to populate information directly into a provider EMR to meet this requirement. Plans can meet the requirement if they can provide requested information (phone, secure email, direct feed, provider portal, file request) to providers who are treating their members. Plans should have documented processes for providing information on how this works to be reviewed as part of the audit.

This applies to the following Programs and Years:

EMRs are limited in the amount of longitudinal information they contain for any one patient. Many data sources meet ECDS requirements. Plans have access to a wealth of information from across a much larger network than any single provider. ECDS is designed to encourage plans and providers to seek alternative sources of data (already being collected) to fill gaps in knowledge about a person’s health care experiences and future requirements.

This applies to the following Programs and Years:

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:

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).

• Option 2: If you have access to the LIS History (LISHIST) File, it can be used to determine LIS eligibility. CMS describes the file as the most complete picture of LIS eligibility over a period not to exceed 36 months. This data file includes LIS activity for past, present and future enrollees. A full copy of the Plan-Communications-User-Guide-v122-August-31-2018, which describes the file, can be found at https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/Plan-Communications-User-Guide-v122-August-31-2018.pdf. Below is an example of the corresponding records in the LISHIST file for the member shown above.

 
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.
 

This applies to the following Programs and Years:

The intent of excluding ED/observation visits that result in an inpatient stay is to not double count events when the diagnosis category is the same for both events. For example, an ED visit for alcohol disorder that resulted in an inpatient stay for alcohol disorder is reported only once in the “Inpatient Stay” category. However, an ED visit for alcohol disorder that resulted in an inpatient stay for opioid disorder is reported in both the ED category (alcohol diagnosis category) and the Inpatient Stay category (opioid diagnosis category). An ED visit for alcohol disorder that resulted in an inpatient stay for something other than an alcohol, opioid or other or unspecified drug disorder (e.g., heart attack) is reported only once in the “ED” category.

This applies to the following Programs and Years:

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.  

This applies to the following Programs and Years:

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)  

This applies to the following Programs and Years: