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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4.14.2017 Comprehensive Diabetes Care Please clarify the instruction to not include BP readings taken on the same day as a diagnostic test or procedure that requires a change in diet or medication. Must the change in diet or medication be required by the procedure? Is the BP eligible if a patient forgets to take their regular medication the day of a procedure? Is the BP eligible if the member receives a vaccine, a nebulizer treatment with albuterol or lidocaine injected prior to an unplanned removal of a small mole?

The intent is to identify diagnostic or therapeutic procedures that require a medication regimen, a change in diet or a change in medication. For example, colonoscopy requires a change in diet (NPO on the day of procedure) and a medication change (a medication is taken to prep the colon). Dialysis, infusions and chemotherapy are all therapeutic procedures that require a medication regimen. A nebulizer treatment with albuterol is considered a therapeutic procedure that requires a medication regimen (the albuterol). Injection of lidocaine prior to mole removal is considered a diagnostic procedure (if the mole is being tested) or a therapeutic procedure (if removal of the mole is the treatment) that requires a change in medication (lidocaine administered for pain control during the procedure). A patient forgetting to take regular medications on the day of the procedure is not considered a required change in medication, and therefore the BP reading is eligible.

 A BP taken on the same day that the patient receives a vaccination is eligible for use. A vaccination is considered preventive medicine and is not considered a therapeutic or diagnostic procedure.

HEDIS 2017

3.15.2017 UM 9 C: Scoring reviewer for appeals of system-made benefit denials Under UM 9, Element C, for an appeal of an initial benefit denial that was made by an automated system (e.g., claims or POS), where a person makes the appeal decision, should the file be scored “NA” or “Yes”?

The file should be scored "Yes.” A person making the appeal decision is different from, and not subordinate to, an automated system.

HP 2017

2.15.2017 Adolescent Well-Care Visits Does documentation of “Tanner stage” meet criteria for the physical exam or physical developmental history component for the Adolescent Well-Care Visits (AWC) measure?

Yes. Documentation of Tanner stage meets criteria for the physical exam and physical developmental components, but should not be double-counted toward both (if used as evidence of physical exam, it may not be used as evidence of physical developmental, and vice versa). Documentation of Tanner stage does not meet criteria for the Well-Child Visits in the First 15 Months of Life (W15) or Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) measures as sexual maturity rating is not recommended until 7 years of age.

HEDIS 2017

2.15.2017 Effective date for Case Management Accreditation 2017 and Termination date of Case Management Accreditation 2014 When will the 2017 CM standards be effective and when will the 2014 CM standards year end?

The 2017 CM standards are effective on or after January 30, 2017. For organizations that have already scheduled a survey through June 30, the 2014 CM standards year will end on June 30, 2017. 

CM 2014

2.15.2017 Standardized Healthcare-Associated Infection Ratio When reporting the columns “Percentage of Total Discharges From Hospitals With Unavailable SIR,” “Number of Contracted Hospitals With Reportable SIR” and “Total Inpatient Discharges” in Table HAI-1/2/3, if a hospital is not listed in Table HSIR, is it included in the count?

Hospitals for which plans have discharges from but are not identifiable in Table HSIR should not be included in the hospitals reported in the category "Number of Contracted Hospitals With Reportable SIR." However, discharges from these hospitals should be included in “Total Inpatient Discharges” and in “Percentage of Total Discharges From Hospitals With Unavailable SIR.” Use Table HSIR posted on the NCQA Web site to make the determination; organizations do not need to refer to the Hospital Compare web site.

HEDIS 2017

2.15.2017 Standardized Healthcare-Associated Infection Ratio In Table HAI-1/2/3, the four columns labeled “Percentage of Total Discharges From ...”. are collected in IDSS using 4 digits after the decimal. Because the columns are percentages, how should the data for these columns be displayed? For example, using HAI-1: Central line associated blood stream infection (CLABSI), if there are 100 contracted hospitals, of which 10 belong to “high” category of Standard Infection Ratio, what should the reported value be?
A) 0.1000
B) 10.0000

Option A. Organizations should report results as a decimal; therefore, option A is correct when reporting in IDSS. IDSS will include a validation that checks for values to be reported between 0 and 1 and must be rounded to 4 decimal places.

HEDIS 2017

2.13.2017 Proportion of Days Covered by Medications (PDC) Are the PDC denominator exclusions required, or optional?

All PDC denominator exclusions are required if the data are available.

IHA 2016

2.13.2017 General Guidelines Should the Value Based P4P General Guideline 19: Members in Hospice guideline apply to all clinical measures? The note that appears in most measures referencing this exclusion and guideline does not appear in the ENRST, PDC or HRM measures.

Yes. Value Based P4P General Guideline 19: Members in Hospice should apply to all clinical measures, including ENRST, PDC and HRM. We will add a note to all clinical measure specifications for the next release of the manual.  

IHA 2016

2.13.2017 Advancing Care Information (ACI) Domain The note on page 143 of the MY 2016 Value Based P4P Manual states: Include all payer types in e-Measure reporting; do not limit to commercial HMO/POS.
For each e-measure, should the patient-level numerator and denominators (Rate 2: PO-level aggregated performance) be limited to the managed care population only, or include all members?

The Value Based P4P program intends to measure all commercial HMO/POS members, but we understand that not all POs can limit their numerators and denominators to specific product lines. For this reason, and because VBP4P is not currently scoring the PO-level aggregated performance, POs may include all payer types. If the PO has the ability to limit the patient population to just commercial HMO/POS, that is also accepted.

IHA 2016

2.13.2017 Advancing Care Information (ACI) Domain Our PO does not have an integrated EHR system, and some of our providers may have contracts with other POs. For each e-measure, should the patient level numerator and denominators (Rate 2: PO-level aggregated performance) be limited to our PO’s members only, or include all patients for the provider?

Based on the potential burden of reporting PO-specific membership and because VBP4P is not currently scoring the PO-level aggregated performance rate, POs may include all patients for the provider. If the provider has the ability to only include the PO’s members, that is also accepted.

IHA 2016

1.15.2017 Reporting RRU Measures for HEDIS 2017 Should health plans report the RRU measures for HEDIS 2017?

No. NCQA suspended collection of the RRU measures for HEDIS 2017 and health plans should not report RRU measures for HEDIS 2017. In 2017 NCQA will decide whether to permanently retire these measures. NCQA will hold a public comment process to aid in the decision. 

HEDIS 2017

1.15.2017 Relative Resource Use for People with Diabetes Should Marketplace plans report the Relative Resource Use for People with Diabetes (RDI) measure for 2017?

No. The RDI measure will be removed from the Quality Rating System. For Marketplace plans, CMS will issue guidance, including, but not limited to, FAQs, updates to the 2017 Technical Guidance and the 2017 Call Letter.

Exchange 2017