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

expand all

3.15.2018 Plan All-Cause Readmissions There is a discrepancy between Step 7 in the Risk Adjustment Weighting section (page 384) and in all the PCR reporting tables for how to calculate the Expected Readmissions Rate. Which one is correct?

Organizations must use the formula in Step 7 to calculate the Expected Readmissions Rate for PCR. The reference in the PCR reporting tables of the “(Expected Readmissions/Den)” is incorrect. The data element should only be “Expected Readmissions Rate.” This removal of the incorrect calculation instruction will be made in the Interactive Data Submission System (IDSS) and data dictionaries.

HEDIS 2018

3.15.2018 Care for Older Adults If the medical record contains a notation of a type of advance care plan (e.g., advance directive, actionable medical orders, living will, surrogate decision maker, full code, DNR) with documentation of “yes” or “no,” does this meet criteria?

If “yes” is documented for a type of advance care plan, this is considered evidence that a member has an advance care plan in place and meets criteria. If “no” is documented, this is considered evidence that the member does not have this type of advance care plan in place and does not meet criteria. For example, documentation of “DNR – No” indicates “the member does not have a DNR,” and does not meet criteria. In addition, documentation of “no” is not considered evidence of an advance care planning discussion (asking if a member has an advance care plan in place and documenting “no” is not considered a discussion).

HEDIS 2018

3.14.2018 VBP4P/ACO- Clinical Measure Data File Layouts With regard to the the AMROV65 measure: The MY 2017 VBP4P manual states that the age span is 5–64, but the PO, HP and ACO layouts all indicate 5–65. Is this correct, or should the ID be “AMROV64” and the age span 5–64?

You are correct: The measure name should be AMROV64.

This is an error in the Clinical Measure Data File Layouts. The AMR total rate should only include members 5–64 years of age, in alignment with the AMR measure specifications. The correction is below. VBP4P staff will make this correction and release a new version of the affected files on iha.org.

Commercial

AMROV64

Asthma Medication Ratio: Ages 5-64

IHA 2017

3.14.2018 VBP4P/MA- Medicare Advantage and Commercial Dual Eligibles If a member is enrolled in both commercial and Medicare Advantage lines of business, assuming both plans participate in VBP4P, in which lines should the member be reported?

HEDIS General Guideline 15: The “Working Aged” and Retirees says, “Include employees 65 years of age and older and retirees only in the product line that providers their primary coverage (Medicare or commercial).” Following this guidance, members with dual coverage in commercial and Medicare Advantage products should be reported in the plan that provides primary coverage (whether the same or a different plan). NCQA will provide further guidance on this issue in HEDIS 2019 and VBP4P will evaluate for inclusion for MY 2018.

Self-reporting POs that are unable to identify the primary insurer should use their best judgment; the overall impact is expected to be minimal and equal across plans and POs.

IHA 2017

2.15.2018 Identifying a member for Complex Case Management When is a member identified as eligible to receive complex case management services?

A member is identified to receive complex case management services in PHM 2, Element D. The organization’s policies and procedures describes its method for categorizing membership for involvement in complex case management. Once identified, the organization must begin the initial assessment within 30 days and complete within 60 days to meet the PHM 5, Element D requirement.

HP 2018

2.15.2018 Adolescent Well-Care Visits Does sports participation meet the criterion for physical developmental history?

Yes. Documentation of participation in sports or in physical activity meets the criterion for physical developmental history. Bright Futures states that a goal of observing development in adolescents is to determine whether they are developing skills for becoming healthy adults—such as good nutrition and physical activity.

HEDIS 2018

2.15.2018 Transitions of Care A member is admitted to the hospital on December 30, 2016, and discharged in January 2017. To meet criteria, the Notification of Inpatient Admission must occur on either December 30 or 31, 2016, but the measure description states that the four elements must occur during the measurement year. Can we count the Notification of Inpatient Admission that occurs in the year prior to the measurement year?

Yes. In the scenario above, Notification of Inpatient Admission may be on the admission date or on the following date, even if it occurs in the year prior to the measurement year. The member in this example remains in the measure because the discharge date was in January 2017. Unless the patient’s PCP or ongoing care provider was involved in the patient’s care prior to the admission (e.g., conducted the patient’s pre-admission exam), a communication on the admission date or the date following meets criteria for the Notification of Inpatient Admission numerator.

HEDIS 2018

2.15.2018 ECDS General Guidelines Should organizations include only paid claims for ECDS measures?

No. Organizations must include all paid, suspended, pending and denied claims for ECDS measures. Currently, ECDS General Guideline 4 states to include only services for which the reporting entity has paid or expects to pay, but because none of the other eligible sources require payment status, any claims should be accepted. The guideline is incorrect and will be corrected for HEDIS 2019

HEDIS 2018

2.12.2018 VBP4P/ACO- HEDIS UPDATE: 2018 NDC List Correction On February 8, 2018, HEDIS released a letter addressing an issue identified in the Asthma Controller Medications List in the HEDIS® 2018 Medication List Directory (MLD) of NDC codes posted to the NCQA website on November 1, 2017. Does this affect health plans and providers participating in IHA performance measurement programs?

Yes. The issue affects the Asthma Medication Ratio (AMR) measure used in commercial HMO and commercial ACO reporting.
The Asthma Controller Medications List incorrectly included codes for nebulizer medications. NCQA issued a correction and has removed the codes from the NDC list. An updated version of the MLD was released on February 8, and IHA released a communication to stakeholders on February 9.

Next Steps for VBP4P

NCQA has identified next steps:

Self-reporting physician organizations and health plans that program AMR are required to download the updated HEDIS® 2018 Medication List Directory (MLD) of NDC codes. NCQA certified auditors have been notified and will review your corrected code during your VBP4P audit.
NCQA certified vendors are required to submit an attestation that the certified vendors have removed the codes from their software.

If your organization contracts with an NCQA certified vendor or a vendor seeking certification, they have been notified and asked to incorporate this update when programming your MY 2017 results.

If you contract with a noncertified vendor, notify your vendor about this change immediately.

IHA 2017

1.15.2018 Transitions of Care The criteria for TRC Notification of Inpatient Admission states that notification should occur on the day of admission or the following day. However, one bullet states that evidence of tests ordered by the PCP during the inpatient stay is valid, as well. If a member stays in the hospital for 10 days, and there is no evidence of the PCP ordering tests until day 4 of the stay, it is this compliant for the indicator?

No. To be compliant for the indicator, documentation that the PCP/care provider ordered tests/ treatment to occur during the inpatient stay must be documented on the day of admission or on the following day. Documentation on day 4 does not count.

HEDIS 2018

1.15.2018 Prenatal and Postpartum Care Is the ability to choose EDD or date of delivery based on the member level or on the organization level?

The determination whether to use EDD or date of delivery is made at the member level. Flexibility is allowed because in the case of pre- or post-term deliveries, the delivery date may not be the most accurate date for determining the first trimester.

HEDIS 2018

1.12.2018 VBP4P- VBP4P Exclusions: Members Impacted by CA Wildfires Is IHA making exceptions for VBP4P reporting for areas affected by the wildfires in California? Will IHA allow an exclusion for members affected by these wildfires?

The VBP4P Governance Committee has approved a program wide optional exclusion for members living in the following zip codes only: 95403, 95404, 95405, 95409.

POs have the option to exclude these members from MY 2017 VBP4P reporting. This exclusion is “all or none”: All members living in these zip codes must be excluded for all measures, regardless of numerator status, if the exclusion is exercised.

IHA 2017