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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10.15.2017 ECDS What auditing process and documentation are required for ECDS sources?

The audit process for HEDIS ECDS measures is evolving. Data sources fall under audit requirements for standard supplemental data. Plans complete a Roadmap for each data source so the NCQA-Certified auditor is aware of all data that are being considered for reporting. Auditors validate policies and procedures for each data source (e.g., file layout, mapping). Although primary source verification is not required, auditors may want to validate the primary source during an initial review of data, to ensure accuracy and validity.

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 ECDS How do EHR vendors submit data and to whom does the submission file go?

Only health plans may submit HEDIS ECDS measure data to NCQA. EHR vendors should work with plans that use their systems to provide data that will be used to calculate HEDIS ECDS measures.

NCQA is currently certifying EHR vendors, to increase the reliability of health IT data used for reporting health care performance. Learn more at:

http://www.ncqa.org/hedis-quality-measurement/certified-survey-vendors-auditors-software-vendors/emeasure-certification.

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 ECDS If the same data source is used as ECDS and as supplemental data, are health plans required to submit separate Roadmaps/documentation?

Plans should work with their NCQA-Certified auditor to accurately identify all data sources being considered for HEDIS reporting, whether the source is used for ECDS measures or for other HEDIS domain measures. If a plan completed an Audit Roadmap (Section 5) and will use the data source for both supplemental data and ECDS, this should be noted.

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 Breast Cancer Screening, Colorectal Cancer Screening, Controlling High Blood Pressure, and Osteoporosis Management in Women Who Had a Fracture The Medicare Monthly Membership File includes a run date and a payment date. Which date should be used to determine that a member had an LTI flag during the measurement year?

Use the run date to determine that a member had an LTI flag during the measurement year.

This applies to the following Programs and Years:
HEDIS 2018

9.15.2017 Appeals covered in QI 4, Element C What types of appeals are included in QI 4, Element C: Coverage Appeals (e.g., in UM 8-UM 9) or noncoverage appeals (e.g., in RR 2)?

QI 4 requires organizations to collect data from all sources of member complaints and appeals. This includes UM coverage appeals addressed in UM 8-UM 9 and noncoverage appeals addressed in RR 2.
 

Note: Data collected and analyzed prior to December 15, 2017,will be accepted as meeting the requirement, even if not all types of appeals are included. Data collected and analyzed on or after this date must comply with the requirement stated in the FAQ.

If your organization collected and analyzed data prior to December 15, 2017, and interpreted the requirement as applying to only one type of appeal, notify the surveyor at the start of the survey so the misinterpretation does not affect scoring.

 

This applies to the following Programs and Years:
HP 2018

9.15.2017 Transitions of Care Are Special Needs Plans (SNPs) and Medicare-Medicaid Plans (MMPs) required to report the Transitions of Care (TRC) measure?

No. In the 2018 CMS Reporting Requirements Memo, the TRC measure is not listed in Table 3, “HEDIS 2018 Measures for Reporting by SNPs and MMP PBPs.”

This applies to the following Programs and Years:
HEDIS 2018

9.15.2017 Denial Notices—Right to Representation The denial notification must include a statement that members may be represented by anyone they choose, including an attorney. If the notification states that members have the right to be represented by anyone, but does not specify “including an attorney,” is this acceptable?

Yes. If the notification indicates that members may be represented by anyone, this is acceptable because the reference to “anyone” implies “including an attorney.” If the notification lists specific types of individuals, it must also specify “an attorney.”

This applies to the following Programs and Years:
HP 2017, 2018|MBHO 2017|UM-CR 2017|UM-CR-PN 2018

9.15.2017 Utilization Management and Use of Voicemail When does voicemail meet UM notification requirements?

Voicemail meets UM requirements only when the organization notifies a practitioner about the opportunity to discuss a denial decision. The organization must document who left the message, along with the date and time it was left. Voicemail messages do not meet any other notification requirement.

This applies to the following Programs and Years:
HP 2017, 2018|MBHO 2017|UM-CR 2017|UM-CR-PN 2018

9.15.2017 Complex Case Management When does the time frame for completing the initial assessment for complex case management begin?

The time frame for completing the initial assessment begins when the member is determined to be eligible for complex case management. A member is eligible once identified using criteria from Element B, factor 2 and data sources in Element C (e.g., claims/encounter data, hospital discharge data). The initial assessment is not used to determine eligibility, although information gathered in the assessment may make a member ineligible.

Note: There is no “opt-in” option for identifying members.
 

This applies to the following Programs and Years:
HP 2017|MBHO 2017

8.15.2017 Breast Cancer Screening, Colorectal Cancer Screening, Controlling High Blood Pressure, and Osteoporosis Management in Women Who Had a Fracture A required exclusion was added to the Medicare product line for members 65 years of age and older living long-term in institutional settings for the Breast Cancer Screening, Colorectal Cancer Screening, Controlling High Blood Pressure and Osteoporosis Management in Women Who Had a Fracture measures. In addition to using the Medicare monthly membership file, may organizations use other data sources when identifying members living long-term in an institution?

No. Organizations may not use other data sources (e.g., supplemental or medical record data) when excluding members living long-term in an institution. The LTI flag in the Medicare Part C monthly membership file is the only source that may be used to identify this exclusion. NCQA was informed by CMS that all Medicare plans receive this file monthly and have access to this flag. NCQA plans to clarify this in the HEDIS 2018, Volume 2 Technical Update Memo, scheduled for release on October 2, 2017.

This applies to the following Programs and Years:
HEDIS 2018

8.15.2017 Use of Opioids From Multiple Providers The Use of Opioids From Multiple Providers (UOP) measure instructs organizations to use the National Provider Identifier (NPI) when identifying prescribers and pharmacies. How should organizations report pharmacy claims for opioids when the prescribing provider and/or pharmacy NPI is missing?

If the prescriber and/or pharmacy NPI is missing, count each dispensing event with a missing NPI as a different prescriber and/or different pharmacy when reporting the measure. NCQA plans to clarify this in the HEDIS 2018, Volume 2 Technical Update Memo, scheduled for release on October 2, 2017.

This applies to the following Programs and Years:
HEDIS 2018

8.15.2017 Overturned appeals Who can overturn a medical necessity or benefit denial on appeal?

NCQA allows any individual at the organization to overturn a denial on appeal. Upheld denials still require same-or-similar specialist review for medical necessity decisions and review by a nonsubordinate for benefit decisions.

This applies to the following Programs and Years:
HP 2017, 2018|MBHO 2017|UM-CR-PN 2018