Yes. Organizations may submit the mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit. This is not required to be specified in the delegation agreement.
MBHO 2023
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.
Filter Results
10.16.2023 UM 12, Element C, factor 2 for mail service delegates Can organizations submit a mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit for UM 12, Element C, factor 2?
10.16.2023 Updated: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?
Yes. Using UM 13: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 13, Element A: Delegation Agreement
- Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution (e.g., UM 11, Element B (annual updates for pharmaceutical restrictions/preferences).
- Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance, if applicable.
- Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
- Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.
UM 13, Element C: Review of the UM Program:
- Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates.
- Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
- Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit. This must be specified in the delegation agreement.
Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.
UM-CR-PN 2023
10.16.2023 Updated: MBHO: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?
Yes. Using UM 12: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 12, Element A: Delegation Agreement
- Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution
- Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance.
- Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
- Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.
UM 12, Element C: Review of the UM Program
- Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates
- Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
- Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit. This must be specified in the delegation agreement.
Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.
MBHO 2023
10.16.2023 CAQH Application: Illegal drug use question (CVO) Does the CAQH application question about lack of current illegal drug use meet the intent of NCQA’s requirement in CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2?
Yes, the following CAQH question meets the intent of the requirement in CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2:
Are you currently engaged in the illegal use of drugs?* ("Currently" means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.)"
CAQH provides additional information regarding what "currently" means that aligns with language in the explanation of CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2 that the organization may use more general or extensive language to query practitioners about impairment.
CVO 2022
9.15.2023 COL-E Age Stratifications in Characteristics The age stratifications listed under the “Characteristics” section of the COL-E header in Volume 2 are not the same as the age stratifications listed in the Data Elements for Reporting table. What are the correct age strata for the measure?
8.25.2023 Change to AR 2023 Criteria - AR TC 1 and AR CC 1 What changes have been made to Annual Reporting 2023?
There has been an update to the PCMH 2023 annual reporting requirements. AR TC 1 ( Staff Involvement in Quality Improvement) and AR CC 1 ( Hospital and ED Coordination) will now require additional documentation to demonstrate practices are meeting requirements. NCQA is requesting a documented process and evidence of implementation in addition to attestation for this criteria. All practices will have the ability to upload necessary documentation in Q-PASS by the end August. Until then, your RP manager may reach out to request additional documents.
PCMH 2017
8.25.2023 CM 04 What is the difference between expected outcome/prognosis and treatment goal for the care plan?
An example of expected outcome/prognosis is typically clinically based. Expected outcome/prognosis is what the expected outcome of complying with the care plan would be. You can think about it as if a patient follows all instructions of the care plan what you are expecting to happen (e.g., their A1C/BMI/stroke risk etc. will decrease). Generally, we see practices differentiate treatment outcome/prognosis as a more clinical metric, for instance lowering A1C by 2 points etc.
Treatment goals are more lifestyle choices or outcomes for the patient, such as eating more vegetables or getting enough exercise to be able to walk around the block etc.
All of these elements are incorporated into the care plan: a problem list, expected outcome/prognosis, treatment goals, medication management and a schedule to review and revise the plan, as needed.
PCMH 2017
8.16.2023 Required Exclusions and Hybrid Reporting For HEDIS MY 2023, optional exclusions are now required exclusions. For hybrid measures, if a member meets exclusion criteria via medical record review, can the member be removed from the measure and replaced with a member of the oversample?
8.16.2023 Kidney Health Evaluation for Patients With Diabetes (KED) What is the intent of removing LOINC code 32294-1 from the Urine Albumin Creatinine Ratio Lab Test Value Set?
The KED measure provides actionable information for chronic kidney disease identification and management. General guidance from our experts is that tests included in the measure should align with guideline recommendations from the American Diabetes Association and the National Kidney Foundation. For this reason, only quantitative uACR tests are allowed and semi-quantitative tests are not considered measure compliant. Removing LOINC code 32294-1 from the value set maintains these coding parameters.
HEDIS 2024
8.16.2023 PCS Questions Do answers from the Policy Clarification Support system have an expiration date?
8.15.2023 Lack of present illegal drug use Does NCQA require practitioners to attest to their lack of present and past illegal drug use?
7.27.2023 Cervical Cancer Screening (CCS) In HEDIS MY 2023, the CCS exclusion for hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix is now a required exclusion. Does documentation of a hysterectomy in combination with documentation that the patient no longer needs Pap testing/cervical cancer screening sufficient to meet criteria as a required exclusion for HEDIS MY 2023 reporting?
No. Members with documentation of “hysterectomy” and documentation indicating that they no longer need Pap testing/cervical cancer screening must remain in the measure for MY 2023 reporting. Members with documentation of a “vaginal pap smear” and documentation of “hysterectomy” must also remain in the measure for HEDIS MY 2023 reporting. This is because the documentation must match the clinical specificity of the codes in the value sets and there are no codes that are clinically synonymous with these examples.
There must be evidence of a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix in order to meet required exclusion criteria for MY 2023 reporting.
Documented “vaginal hysterectomy” or “complete/total/radical hysterectomy” that matches a definition in applicable value sets may be used to meet criteria, subject to auditor approval.
HEDIS 2023