The file should be scored "Yes.” A person making the appeal decision is different from, and not subordinate to, an automated system.
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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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”?
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.
This applies to the following Programs and Years:
HEDIS 20172.15.2017 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?
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.
This applies to the following Programs and Years:
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.
This applies to the following Programs and Years:
HEDIS 20172.13.2017 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.
2.13.2017 Proportion of Days Covered by Medications (PDC) Are the PDC denominator exclusions required, or optional?
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.
This applies to the following Programs and Years:
IHA P4P2.13.2017 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.
This applies to the following Programs and Years:
IHA P4P1.15.2017 Statin Therapy for Patients With Cardiovascular Disease There appear to be additional NDC codes for high- and moderate-intensity statins included in the NDC list for SPD-A that are not in SPC-B. May these additional codes be mapped to the HEDIS 2017 NDC list for table SPC-B?
Yes. Organizations may map NDC codes so that the same set of codes for high-intensity and moderate-intensity statins are used for both the SPC-B and SPD-A measures. An NDC code that is not on the HEDIS list may be used if its generic name, strength/dose and route match an NDC code on the HEDIS list. Organizations should document the method used to map codes: Mapping is subject to review during a HEDIS Compliance Audit. Requirements for mapping are described in General Guideline 50 in HEDIS 2017 Volume 2.
This applies to the following Programs and Years:
HEDIS 20171.15.2017 Reporting the Aspirin Use and Discussion measure for HEDIS 2017 Will NCQA collect or report results for the Aspirin Use and Discussion measure for HEDIS 2017?
No. NCQA has decided to retire the Aspirin Use and Discussion (ASP) measure due to misalignment with updated recommendations from the United States Preventive Services Task Force (USPSTF). The updated USPSTF aspirin recommendations include a calculation of 10-year cardiovascular risk and an estimate of 10-year life expectancy. This information would be required to identify the denominator of the ASP measure and because it cannot be captured in the Consumer Assessment of Healthcare Providers & Systems (CAHPS) Health Plan Survey or claims data, we are unable to adapt the measure to be consistent with the USPSTF findings.
The aspirin questions remain in the HEDIS 2017 CAHPS questionnaire but member responses to the questions will not be submitted to NCQA by the certified survey vendor. The questions will be removed from the HEDIS 2018 CAHPS questionnaire.
This applies to the following Programs and Years:
HEDIS 20171.15.2017 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.
