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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1.15.2017 UM 7 B: Specific criterion referenced in a denial decision In UM 7, Element B, factor 2, organizations are required to reference the specific criterion used to make a denial decision. How specific does the criterion need to be?

The criterion referenced must be identifiable by name and must be specific to an organization or source (e.g., ABC PBM’s Criteria for Treatment of Hypothyroidism with Synthroid or CriteriaCompany Inc.’s Guidelines for Wound Treatment). If it is clear that the criterion is attributable to the organization, it is acceptable to state “our Criteria for XXX” (e.g., our Criteria for Treating High Cholesterol with Lipitor).

Note: This also applies to Element E and Element H in HPA and Element E in UM-CR.

This applies to the following Programs and Years:
HP 2017|MBHO 2017|UM-CR 2017, 2016

1.06.2017 Proportion of Days Covered by Medications The December 1, 2016 release of the PDC measure specification includes a new exclusion table, Renin Angiotensin System (RAS) Antagonists Exclusions (Table PDC-E). Row 10 of the “Overview” tab in the Excel file named “03_MY_2016_NDC_List_for_PQA-developed_measures_2016-12-01” includes the PQA Measure Drug Category: Insulin (exclusions), but corresponds to P4P table “PDC-E”, should this actually correspond with P4P table “PDC-D”?
If the above was an error, can you clarify where the codes for the ARB/Neprilysin Inhibitor Combination Medication (Table PDC-E) can be found?

You are correct, cell D-10 in the "Overview" tab should say "PDC-D" as this refers to the Insulin Exclusions (Table PDC-D) and NOT the Renin Angiotensin System (RAS) Antagonists Exclusions (Table PDC-E). We will fix this for the next release of the file and work with the measure developer to add an additional row that includes the exclusion table (PDC-E).

The data for the Renin Angiotensin System (RAS) Antagonists Exclusions (Table PDC-E) can currently be found in the RASA tab, in rows 4661-4672. This drug is also flagged in column L: "Denominator_Exclusion_Flag".

This applies to the following Programs and Years:
IHA P4P

12.28.2016 Proportion of Days Covered by Medications (PDC) Can you clarify the timeframe for the new Renin Angiotensin System (RAS) Antagonists denominator exclusion: “Patients dispensed at least one prescription for an ARB/Neprilysin Inhibitor Combination Medication (Table PDC-E)”?

The timeframe for this denominator exclusion should be any time during the treatment period and should read as follows:
 “Patients dispensed at least one prescription for an ARB/Neprilysin Inhibitor Combination Medication (Table PDC-E) any time during the treatment period.”

We will make this update for the next version of the VBP4P Manual.

This applies to the following Programs and Years:
IHA P4P

12.22.2016 Standardized Healthcare-Associated Infection Ratio How does NCQA determine that an acute care hospital is contracted with a health plan?

For reporting HAI for HEDIS 2017, NCQA defines a contracted acute care hospital as any acute care hospital to which the organization paid a claim for a member’s inpatient stay during the measurement period. This is a first-year measure; based on the results, NCQA may review this definition for changes in 2018.The FAQ posted in October regarding this topic was retracted given the release of the FAQ above.

This applies to the following Programs and Years:
HEDIS 2017

12.15.2016 Allowing Automatic Credit for UM 13, (UM 12 in HP 2017) Elements A and B for Interim Surveys Is automatic credit available for Interim Surveys for organizations that delegate UM 13 (UM 12 in HP 2017), Triage and Referral for Behavioral Healthcare, Elements A and B to an NCQA-Accredited/Certified health plan, MBHO or UM-CR?

Yes. Automatic credit is available for an Interim Survey if the organization delegates to an NCQA-Accredited/Certified health plan, MBHO or UM-CR. The delegate’s Accreditation/Certification Survey must include the specific elements or factors for which the organization seeks automatic credit. The organization is responsible for determining if delegated activities are covered in the scope of the delegate’s NCQA review.

This applies to the following Programs and Years:
HP 2017

12.15.2016 PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults and Depression Remission or Response for Adolescents and Adults If an organization chooses to report the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS) and Depression Remission or Response for Adolescents and Adults (DRR) measures, must the data be audited?

No. The DMS and DRR measures are not required to be audited for HEDIS 2017.

This applies to the following Programs and Years:
HEDIS 2017

12.15.2016 Plan All-Cause Readmission Does the Note at the end of step 4 (page 347) regarding required exclusions of the denominator of the administrative specification also apply to step 3 of the numerator (page 352)?

Yes. Add the following language to step 3 of the numerator: Note: For hospital stays where there was an acute-to-acute direct transfer (identified in step 2), use both the original stay and the direct transfer stay to identify exclusions in this step.

This applies to the following Programs and Years:
HEDIS 2017

12.15.2016 Comprehensive Diabetes Care Organizations are instructed to exclude BPs taken on the same day as a diagnostic test or procedure that requires a change in diet or medication regimen on or one day before the day of the test or procedure (with the exception of fasting blood tests). May organizations exclude BPs on the same day as a procedure that typically requires a change in diet/medication or must the medical record documentation specifically state there was a change in diet/medication?

If it is standard practice to change diet or medications prior to a procedure, then exclude BPs on the same day as that procedure. For example, a colonoscopy requires a change in diet combined with bowel prep prior to the procedure. Therefore, BPs on the day of a colonoscopy are excluded even if the medical record documentation does not contain specific notation about a change in the member’s diet. Should organizations require support in identifying procedures where a diet or medication change is standard practice, they must consult with their internal clinical staff or their HEDIS auditor.

This applies to the following Programs and Years:
HEDIS 2017

12.15.2016 Controlling High Blood Pressure Organizations are instructed to exclude BPs taken on the same day as a diagnostic test or procedure that requires a change in diet or medication regimen on or one day before the day of the test or procedure (with the exception of fasting blood tests). May organizations exclude BPs on the same day as a procedure that typically requires a change in diet/medication or must the medical record documentation specifically state there was a change in diet/medication?

If it is standard practice to change diet or medications prior to a procedure, then exclude BPs on the same day as that procedure. For example, a colonoscopy requires a change in diet combined with bowel prep prior to the procedure. Therefore, BPs on the day of a colonoscopy are excluded even if the medical record documentation does not contain specific notation about a change in the member’s diet. Should organizations require support in identifying procedures where a diet or medication change is standard practice, they must consult with their internal clinical staff or their HEDIS auditor.

This applies to the following Programs and Years:
HEDIS 2017

12.15.2016 Revising Data Sources for MBHO QI 7, Element A and B What are the correct data sources for QI 7, Element A and B for MBHO 2016?

NCQA reviews documented process and materials. The Policy Update posted on 11/21/16 was incorrect.

This applies to the following Programs and Years:

12.15.2016 UM 9, Element D: Including Reviewers Names on Appeal Decision Letters Are organizations required to include reviewers’ names on appeal letters or verbally communicate to members that names are available upon request?

No. Organizations are not required to include reviewer names on the decision letter or verbally inform members that the information is available upon request. This language will be removed from UM 9, Element D in the March Policy update.

Please note this requirement remains in UM 8, Element A. 

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

12.09.2016 VBP4P Value Set Directory It appears that the Value Based P4P Value Set Directory (VSD) released on December 1, 2016, is missing the leading zeros for ICD-9 codes in a multiple value sets. For example, 079.4 is showing as 79.4 and 042 is showing as 42. Is there a version of the VBP4P Value Set Directory that includes the correct codes?

Thank you for bringing this to our attention, select codes within the December 1 version of the Value Set Directory file contained errors; leading and trailing zeros were unintentionally dropped from ICD-9 and Uniform Bill Codes.

 

NCQA has corrected this issue and updated the impacted files in the Download Center site as of 12.08.16. To obtain the updated versions, log into Download Center with your NCQA login credentials (email address) and re-download the MY 2016 Value Based P4P Manual and Value Set Directories zip file. The updated files inside will reflect the date of 12.08.16 in the file name.

 

We apologize for any inconvenience or confusion caused by this error.

This applies to the following Programs and Years:
IHA P4P