Factors 7-13 should be scored as “Met” for upheld denials sent to MAXIMUS.
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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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3.15.2019 UM 8, Element A MAXIMUS What factors are scored “Met” for UM 8, Element A if an upheld denial was sent to MAXIMUS?
3.12.2019 PCMH Criteria and HIEs Can utilization of a Health Information Exchange (HIE) meet PCMH criteria?
Participating in an HIE can help practices demonstrate PCMH criteria; however, connection alone does not demonstrate the evidence needed to meet the following criteria. Practices must demonstrate how they use the HIE to meet each criterion. Utilization of an HIE could help meet the following criteria:
|
PCMH Criteria |
NYS PCMH |
|
|
AC 12(2 Credits) |
Continuity of Medical Record Information |
✔ |
|
CM 09(1 Credit) |
Care Plan Integration |
✔ |
|
CC 15(Core) |
Sharing Clinical information |
|
|
CC 17(1 Credit) |
Acute Care After-Hours Communication |
|
|
CC 18(1 Credit) |
Information Exchange During Hospitalization |
|
|
CC 19(1 Credit) |
Patient Discharge Summaries |
✔ |
|
CC 21(Maximum 3 Credits) |
External Electronic Exchange of Information |
✔ |
This applies to the following Programs and Years:
PCMH 20172.15.2019 Plan All-Cause Readmissions (PCR) The “Total” data elements for Medicare in Table PCR-A must match the “Total Medicare” data elements in Table PCR-B. Are organizations required to report the totals in both tables?
No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-A. Remove the “Total Medicare” row from Table PCR-B that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-A. The asterisked language may also be removed under these two tables.
This applies to the following Programs and Years:
HEDIS 20192.15.2019 Supplemental Data When pharmacy data are classified as supplemental data, the following data elements must be present: the generic name (or brand name), strength/dose, route and date when the medication was dispensed to the member. If all the required data elements are included except the dispense date, can a start date be used instead?
2.15.2019 Language in denial letters May an organization send a single denial letter to a member and a practitioner that contains the reason for the denial in both layman terms (for the member) and clinical terms (for the practitioner)?
Yes. The organization may send a single letter to the member and practitioner that includes the specific reason for the denial, in language that would be easily understood by the member. The letter may also include, in a separate section, additional clinical or technical language directed toward a practitioner.
When NCQA reviews the letter to ascertain if the reason for the denial would be easy for the member to understand, it considers both the written reason and the context of the language and whether the information can be understood in context.
This applies to the following Programs and Years:
HP 2018, 2019|MBHO 2018, 2019|UM-CR-PN 2018, 20192.15.2019 Plan All-Cause Readmissions (PCR) The “Total” data elements for Medicare in Table PCR-C must match the “Total Medicare” data elements in Table PCR-D. Are organizations required to report the totals in both tables?
No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-C. Remove the “Total Medicare” row from Table PCR-D that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-C. The asterisked language may also be removed under these two tables.
This applies to the following Programs and Years:
HEDIS 20191.24.2019 KM 02G Resource
SDOH Roadmap
https://healthleadsusa.org/resource-library/roadmap/
This applies to the following Programs and Years:
PCMH 20171.15.2019 Risk of Continued Opioid Use (COU) When calculating the number of days covered for the COU measure’s numerators, must the days be consecutive?
No. The covered days are not required to be consecutive when reporting the numerators of the measure. Review all dispensed opioids on the IPSD through the 30-day or 62-day period and follow the instructions for calculating number of days covered for the numerator. For example, if the IPSD is 1/1/18 and the member has an eligible prescription with a 5-day supply and another eligible prescription with a 10-day supply on 1/10/18, the member meets criteria for the ≥15 Days Covered numerator.
This applies to the following Programs and Years:
HEDIS 20191.15.2019 Medication Management for People With Asthma (MMA) and Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA) In HEDIS 2019, step 4 of the numerator calculation was revised to indicate that the ratio should be rounded to the nearest whole number using the .5 rule. Should the value that is calculated using the formula in the measure be multiplied by 100 before rounding to the nearest whole number using the .5 rule?
Yes. The new rounding directions in step 4 are meant to treat the calculated decimal result as a whole number from 0%–100% for the SAA and MMA measures. For example, if a member has 291 total days covered by a medication during a 365-day treatment period, this calculates to 0.7972. Multiply this number by 100, convert it to 79.72% and round it to 80%, the nearest whole number.
This applies to the following Programs and Years:
HEDIS 20191.15.2019 Comprehensive Diabetes Care (CDC) If documentation in a 2018 visit note indicates “No Diabetic Retinopathy as of Ophtho note on 9/2017,” does this meet criteria as a negative retinal exam?
Yes. This meets criteria for HEDIS 2019 reporting because the documentation indicates that the eye exam was completed by an eye care professional (optometrist or ophthalmologist), the date when the procedure was performed was within the appropriate time frame and the results are present (a negative retinal exam in the year prior to the measurement year).
This applies to the following Programs and Years:
HEDIS 20191.15.2019 Adult BMI Assessment (ABA) There was a change to the ICD-10 coding guidelines, effective October 1, 2018, related to the codes for reporting body mass index (BMI). The change allows providers to bill for BMI codes only if the member has a clinically relevant condition, such as obesity. How does this change affect reporting the ABA measure?
The ICD-10 coding change affects only the administrative-reporting method. Following the new guidelines, a provider would submit a claim with a BMI or BMI percentile code only when there is an associated diagnosis (e.g., overweight, obesity) that meets the new requirements. “Healthy weight” is not considered an associated diagnosis. As a result, members in the denominator, whose only visit is in October, November, or December of 2018, without an appropriate ICD-10 code, due to the lack of an associated diagnosis, will not have claims that meet the current numerator criteria.
NCQA’s analysis shows that, because this measure is reported primarily through the hybrid-reporting option, the effect will be small. This change does not affect organizations using the hybrid method, because the rule pertains to only the use of ICD-10 codes on claims. It does not prohibit providers from measuring and documenting a BMI in the medical record.
This applies to the following Programs and Years:
HEDIS 20191.15.2019 Death as an Exclusion in HEDIS Is death a valid exclusion for HEDIS measures?
NCQA expects plans to disenroll deceased members. Members who died during the continuous enrollment period would not meet the measure’s eligible population criteria (e.g., continuous enrollment and anchor date requirements) and would not be included in the measure denominator. However, a member who meets the continuous enrollment criteria remains in the measure. For example, when reporting the MRP measure, a member who was discharged on July 1 and died on August 1, but enrollment data indicates the member is enrolled in the organization during the continuous enrollment period (the date of discharge through 30 days after discharge) must remain in the measure.
Keep in mind that organizations may not use other data sources (e.g., medical record data) when removing deceased members.
