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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11.15.2017 Use of Opioids at High Dosage In the HEDIS 2018 Volume 2 Technical Update memo Table UOD-A includes a variable ranging from 4-12 for the MED Conversion Factor for methadone based on mg/day of methadone used. However, in the HEDIS 2018 NDC MLD Directory all NDCs for Methadone under the medication list "Opioid Medication" have a MED Conversion Factor (column M) of 3. For performing the MED calculation in UOD, which MED Conversion Factor should be used for methadone?

For HEDIS 2018 reporting, for methadone, the MED conversion factor of "3" should be used as listed in the NDC list; not the factors listed in Table UOD-A. We will reevaluate using the sliding scale conversion factors for HEDIS 2019.

HEDIS 2018

11.15.2017 General Guidelines General Guideline 17 says that "Members with dual commercial and Medicaid coverage must be reported in the commercial HEDIS reports. These members may be excluded from the Medicaid HEDIS reports." If a member has primary insurance in a Medicaid plan and secondary insurance in another Medicaid plan at any time during the measurement year, should the secondary Medicaid plan report the member in their HEDIS report?

To meet criteria for dual coverage, the member should have dual coverage at the end of the continuous enrollment period (dual coverage is assessed on a measure-by-measure basis). For example, if a measure's continuous enrollment period ends on December 31 of the MY and has dual Medicaid and commercial enrollment on that date, then the member may be excluded from the Medicaid HEDIS reports for the measure and only be reported in the commercial product line (General Guideline 23 in HEDIS 2018 Volume 2). In cases where the member is dually enrolled in two Medicaid plans, the secondary Medicaid payer would have the choice to exclude the member if the primary Medicaid coverage was offered through a different organization.

HEDIS 2018

11.15.2017 DEA or CDS Certificates Is a photocopy of a practitioner's DEA certificate acceptable documentation for CR 3, Element A, factor 2?

Yes. Although photocopies are generally not acceptable documentation for verifying credentialing information, they are accepted for DEA certification because the DEA does not provide phone or written verification.

HP 2018

11.15.2017 The Value-based Payment worksheet What is the Value-Based Payment worksheet for PHM 3B, and where can we find it?

The Value-Based Payment worksheet gives instructions on required reporting to satisfy element PHM 3B: Value-Based Payment Arrangements. It is a workbook that must be completed as part of the survey tool.

HP 2018

11.15.2017 Delegation of NET Directories How is NET 7, Element E, factor 1 scored when an organization delegates only the directory functions in NET 6?

The organization is scored NA for factor 1 because the physician and hospital directories do not involve network management procedures.

HP 2018

11.15.2017 Updated: Timeliness of postservice appeal decisions for Medicare and Medicaid Does the recent change for Medicare and Medicaid postservice appeals from 60 calendar days to 30 calendar days align with Chapter 13 of the Medicare Managed Care Manual?

No. Medicare product lines continue to follow the 60-calendar-day time frame for postservice appeals.

Note: The requirement is correct for Medicare product lines; Medicaid product lines continue to follow the 30-calendar-day time frame for postservice appeals.

HP 2018

11.09.2017 Additional Resources Are there any outside resources that may help me in the PCMH transformation process?

Content Area	Criteria	Resource Link	Description
TC	02	http://www.ihi.org/resources/Pages/Changes/OptimizetheCareTeam.aspx	Resource on how to optimize staff responsibilities
	02	https://www.integration.samhsa.gov/operations-administration/OATI_Tool3_ART.pdf	Toolkit on how to optimize administrative staff responsibilities to benefit clinical practice
	02	http://www.improvingprimarycare.org/team/pcp	Resource on how to optimize staff responsibilities
	04	https://www.stepsforward.org/modules/pfac	Module teaching how to create a patient advisory council
	07	http://www.nachc.org/research-and-data/prapare/toolkit/	Toolkit to better understand social determinants of health
	08	https://integrationacademy.ahrq.gov/sites/default/files/AHRQ_AcademyGuidebook.pdf	Information on behavioral healthcare integration in primary practice
KM	02 G	https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/	Social needs screening toolkit
	12	https://www.cdc.gov/media/releases/2012/p0614_preventive_health.html	Discussion on benefits of preventative care
	14	https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/match/match.pdf	Guide to medication reconciliation at transitions
	16	http://www.teachbacktraining.org/	Information on teach back training
	17	http://www.improvingprimarycare.org/work/medication-management	Guide to medication management
	24	https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html	Toolkit for shared decision making
	24	http://msdmc.org/3-assess/	Toolkit for shared decision making
	24	https://shareddecisions.mayoclinic.org/	Informative website about shared decision making
	13	http://www.jabfm.org/content/28/2/170.full.pdf	"Patient Empanelment: The Importance of Understanding Who Is at Home in a Medical Home"
AC	13	http://www.annfammed.org/content/10/5/396.full	"Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation"
		http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/aug/1764_hong_caring_for_high_need_high_cost_patients_ccm_ib.pdf	Article discussing benefits and strategies to care management
CM	03	https://nf.aafp.org/Shop/practice-transformation/risk-stratified-care-mgmt-rubric	Risk stratification rubric available to members of the AAFP
	03	http://www.calquality.org/storage/documents/cqc_complexcaremanagement_toolkit_final.pdf	Risk stratification rubric from California Quality Collaborative
	03	http://www.millimanriskadjustment.com/	MARA – The Milliman Advanced Risk Adjuster is a model of risk stratification in which risk scores are normalized to a given population.
	04	http://www.aafp.org/fpm/2015/0100/fpm20150100p7-rt1.pdf	Care Plan template from AAFP, not exclusive to members
	06	http://www.dartmouthatlas.org/downloads/reports/preference_sensitive.pdf	Resource on how to incorporate patient preference into care management
	08	http://www.ihi.org/resources/pages/tools/selfmanagementtoolkitforclinicians.aspx	Toolkit to aid clinicians in promoting self-management
	08	https://www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/index.html	Resources on self management
	08	http://champsonline.org/tools-products/clinical-resources/patient-education-tools/patient-self-management-tools	Condition specific self management tools
	08	https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/	Article discussing proper communication between primary and specialist clinicians
CC	14	http://nihcr.org/analysis/improving-care-delivery/prevention-improving-health/ed-coordination/	Information on improving communication between emergency and primary physicians
	16	https://share.kaiserpermanente.org/article/kaiser-permanente-study-finds-tailored-post-hospital-visits-lower-risk-readmission-medicare-advantage-patients/	Article discussing advantages of post hospital primary care visits
QI		https://www.ahrq.gov/sites/default/files/publications/files/pcmhqi2.pdf	Resource for building quality improvement in primary care
	03	http://www.ihi.org/resources/Pages/Measures/ThirdNextAvailableAppointment.aspx	Information on how to utlize third next available appointment measurement
	08	https://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod4.html	Benefits of PDSA cycle

PCMH 2017

10.15.2017 ECDS If case management data are used only by behavioral health-care providers (not by primary care providers), may these data be an ECDS data source?

Case management data may be used for measures using the ECDS reporting method if the information collected by case managers is available on request to all providers treating the same member in another setting.
Data are not required to be accessed to qualify for ECDS reporting, but must be available on request to providers providing care to the member.

HEDIS 2018

10.15.2017 ECDS May electronic data feeds from groups that include screenings be used if depression screening results are included?

Electronic data feeds are appropriate for ECDS reporting if they include the standard data required by the measure specifications (e.g., PHQ-9 total score, LOINC code for alcohol screening performed).
All data sources used for ECDS reporting must be reviewed and approved by NCQA-Certified auditors to ensure they meet domain requirements.

HEDIS 2018

10.15.2017 ECDS Is the “care team accessibility” requirement fulfilled if a member’s health record is available online and the provider can access it with the member present or with the member’s consent?

Yes. If a member’s record is available on request to any member of the care team, the requirement is met.

HEDIS 2018

10.15.2017 ECDS May we use depression screening performed by case managers who are employees of a health plan and are not part of an external provider group directly serving the member?

Yes. Data collected by care/case managers employed by a health plan are appropriate, and are reported in the Case Management category in the measure report.

Care/case managers are considered part of the member’s care team because they help members manage a condition and/or their use of health care services.

HEDIS 2018

10.15.2017 ECDS Must a specific provider type be able to access ECDS sources?

No. Member data collected to report a HEDIS measure using the ECDS reporting methodology must be accessible to the care team.

HEDIS 2018