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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7.15.2018 Medical necessity review for personal care services Does NCQA require medical necessity review for personal care services, such as cooking, cleaning and transportation?

No. Medical necessity review is not required for personal care services and other activities of daily living in UM 4–UM 7. However, if these services are covered benefits, any denial decision may be appealed and is included in the scope of appeal file review for UM 9.

HP 2018

7.09.2018 KM 08 (Pediatric Specific) Are there health literacy training programs tailored to pediatric practices?

No, but health literacy training programs are only a suggested approach for addressing communication needs and reducing barriers for patients and their families to access and understand health and safety information.

  • AAP resources: 
           – AAP Pedialink course on health literacy: https://shop.aap.org/health-literacy/  
  • Other resources:
HRSA: Culture, Language, and Health Literacy Tools & Resources: https://www.hrsa.gov/about/organization/bureaus/ohe/health-literacy/resources/index.html  

 

 

PCMH 2017

6.14.2018 CM 08 (Pediatric Specific) Does the asthma action plan count as a self-management tool for pediatric patients?

If the asthma action plan enables patients to track/monitor their progress and document health information at home using a form or some other method of documentation with helpful instructions for self-management, then it would be acceptable.

PCMH 2017

6.14.2018 AC 06 (Pediatric Specific)` If a pediatrician sees more than one child from the same family during one visit, does this meet the requirement for an alternative clinical encounter?

No. Shared appointments would not meet the requirement. Alternative appointments need to be offered through telephone or other technology-supported mechanisms.

PCMH 2017

6.14.2018 QI 01 (Pediatric Specific) Can a practice use the CHIPRA Initial Core Set of Children’s Health Care Quality Measures?

Yes. Measures from the CHIPRA Initial Core Set meet the requirements.

PCMH 2017

6.14.2018 CC 12 (Pediatric Specific) • AAP resource:

6.14.2018 KM 12A (Pediatric Specific) Other than well-child visits, provide some examples of preventative care services that qualify for outreach in a pediatric population

For younger children, practices may also identify patients and provide outreach for services for developmental screenings, autism screening, oral health risk assessment, Hematocrit or Hemoglobin screening, iron supplements for children ages 6 to 12 months at risk for anemia, or tuberculin testing for children at higher risk for tuberculosis  

For adolescent patients, other preventive care services could also include (but not limited to) patients in need of specific preventive care-related lab tests, alcohol and drug screening, cervical dysplasia screening for sexually active females, sexually transmitted infection prevention counseling for adolescents at higher risk, obesity screening and counseling, HIV screening for adolescents at higher risk or other required screenings (e.g., chlamydia, depression, dyslipidemia at specific ages).
 

AAP resources: 

 
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PCMH 2017

6.14.2018 KM 12B (Pediatric Specific) Do Tdap and DTaP count as two different immunizations?

No. Although the immunizations are different formulations, Tdap and DTaP are integrally related. For this reason, NCQA considers them the same immunization for different age groups and does not accept them as two different immunizations.

PCMH 2017

6.14.2018 CM 01A (Pediatric Specific) Can NCQA provide some examples of behavioral health conditions other than ADHD, depression and anxiety that are appropriate for pediatric practices?

Pediatric examples for behavioral health conditions would also include but are not limited to autism or ASD, downs syndrome, Asperger's, cerebral palsy, or developmental delay.

PCMH 2017

6.14.2018 KM 12C (Pediatric Specific) Give examples of pediatric acute care services.

A reminder to schedule a follow-up visit related to an infection (e.g., otitis media, pharyngitis, urinary tract infection) or an injury (e.g., fracture, burn or cut requiring stitches) applies as an acute care service. 

PCMH 2017

6.14.2018 KM 02E (Pediatric Specific) Would unhealthy behaviors associated with a parent’s behavior be acceptable for KM 02 E since they are responsible for preventing these behaviors?

Yes, unhealthy behaviors can be the result of parent behavior but ultimately, we're looking for the unhealthy behaviors demonstrated by the patient (child). Secondhand smoke may be a direct example of a parent’s behavior affecting the child’s health and poor oral hygiene may be a child’s unhealthy behavior, but could result from lack of parental oversight or health literacy.

PCMH 2017

6.14.2018 TC 03 (Pediatric Specific) What are some examples of PCMH-oriented collaborative activities for pediatric practices?

Pediatric practices may want to look into quality improvement projects offered by state AAP chapters and national AAP. The AAP QI Webpage lists a variety of opportunities: https://www.aap.org/en-us/professional-resources/quality-improvement/Pages/ActivityList.aspx

PCMH 2017