Yes. The correct age stratifications are 18-44, 45-64, 65+.
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 Unhealthy Alcohol Use Screening and Follow-Up In the updated measure specification that was released with the HEDIS 2018 Volume 2 Technical Update, the Data Elements table includes a stratification for ages 44-64. Should this age stratification be 45-64?
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?
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?
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 20189.15.2017 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 20179.15.2017 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 20189.15.2017 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 20188.15.2017 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 20188.15.2017 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 20188.15.2017 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 20185.15.2017 Updated: Pharmacists as Same-or-Similar Specialists May pharmacists be considered “same-or-similar” specialists?
No. Beginning with files processed on and after February 1, 2017, pharmacists are not considered same-or-similar specialists because they do not treat patients in most instances.
Note: An FAQ communicating that pharmacists are not considered same-or-similar specialists was posted on October 15, 2016, and this policy was applied beginning February 1, 2017 (90 days from notification).
This applies to the following Programs and Years:
HP 2017|MBHO 2017|UM-CR 20175.15.2017 QI 5 Element G: Complex Case Management Assessment and Evaluation Is collecting information or data only for each factor sufficient to meet the “assessment” or “evaluation” requirements in QI 5, Element G (QI 9, Element G in MBHO)?
No. Presenting data alone is not sufficient. The case manager must draw a conclusion from the data and note it in the member’s file.
Note: Effective for complex case management files that were opened on or after September 1, 2017.
