FAQ Directory

No. HEDIS for QRS requires collection of only Combination 2 and related antigens. IMA will not be scored this year.

This applies to the following Programs and Years:

No. Organizations may not use mass communication for this element. Organizations have three options to notify practitioners of the opportunity to discuss a denial:
1. In the denial notification (included in the denial file).
2. By telephone (time and date of the denial included in the denial file).
3. In materials sent to the treating practitioner, informing the practitioner of the opportunity to discuss a specific denial with a reviewer (evidence that the practitioner was notified that a physician or other reviewer is available to discuss the denial included in the denial file).
 

This applies to the following Programs and Years:

No. Because pharmacists do not treat patients, they are not considered same-or-similar specialists.

This applies to the following Programs and Years:

The following denials (rejections) are included in the scope of UM 4, Element H (UM 4, Element F in MBHO and UM-CR):

• Claims for prescriptions that were refilled too soon.
• Claims for prescriptions with the incorrect dosage or quantity.*
• Claims that were denied because the organization’s reasonable filing procedures were not followed (e.g., lack of prior authorization).

* Inaccurately filed claims that were rejected because of incorrect dosage or quantity may be considered pending until a decision is made. If the request is denied, the claim is included in the scope of UM 4, Element H.

This applies to the following Programs and Years:

The following types of denials are excluded from the file review for UM 4, Element H (UM 4F in UM-CR and MBHO):

• Denials based on medical necessity.
• Postservice payment disputes where the member is not at financial risk.
• Denials by the secondary insurance organization, based on coordination of benefits, when the member has not filed a claim with the primary insurance.
• Denials of vision, dental or alternative/complementary medicine services not included in the member’s medical benefits or included as a rider.
• Denials of duplicate claims, even if there are other reasons for the denial.
• Denials of claims for the following reasons:
  • A service included in a bundled or case rate that is incorrectly billed separately.
  • Incorrect or missing provider billing information (e.g., tax ID).
  • The member was not eligible on the date of service.
  • Nonexistent CPT or ICD code.

This applies to the following Programs and Years:

For the 2016 standards year, NCQA evaluates and scores the UM 4, Element H file review as normal during the onsite survey.
The final score will be adjusted, after the onsite survey, to 100% if the organization includes all denials required by UM 4, Element H in the file review universe. 
If the organization does not include all denials in the file review universe, NCQA will adjust the organization's final score to 50% for the 2016 standards year and 0% thereafter.
 

This applies to the following Programs and Years:

The updated Value Set Directory (VSD) is available to customers who purchased HEDIS 2017 Volume 2. Go to the NCQA Download Center to obtain the file: https://downloads.ncqa.org/customer/Login.aspx.
Note: The updated VSD is not labeled “10-3” in the Download Center. Click “Download” and the file name will include the date 10.03.16.

This applies to the following Programs and Years:

As stated in the measure guidance section for the DMS and DRR measures, include encounters where a diagnosis of major depression or dysthymia was addressed. The intent is to use encounters that are associated with managing depression to identify members in the Initial Population and to identify encounters to be included in the denominator calculation for Rate 2. In the HEDIS 2017 October Update, the Depression Encounter Value Set was renamed Interactive Outpatient Encounter Value Set, to clarify that it identifies outpatient encounters that can take place in a variety of settings. These encounters must be associated with a diagnosis of major depression or dysthymia in order to meet the intent of the measures.

This applies to the following Programs and Years:

No.  Use February 28 of the measurement year when identifying the Age of the member for Rate 1 and Rate 2.  NCQA does not make changes that impact software programming after the release of the Technical Update memo.

This applies to the following Programs and Years:

Yes. Organizations may make this change to the CDC measure. On page 143, in step 1 of the Medical Record, organizations may delete the second and third bullets and add the following bullet:

• 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.

NCQA allows organizations to make this change because it does not impact software programming for the measure.  If an organization makes this change, it must do so consistently across all members.

This applies to the following Programs and Years:

The following types of denials are included in file review for UM 4, Element H (UM 4F in UM-CR and MBHO):

• Denials based on benefits that underwent a medical necessity review, which determined there was a benefit exclusion.
• Denials based on failure to follow the organization’s reasonable filing procedures. (i.e., lack of timely filing, lack of prior authorization).
• Auto-adjudicated claims denials or point of service (POS) claim denials that were not based on medical necessity (excluding duplicate claims).
• Denials not listed above that are not based on medical necessity, such as reversals or prior decisions due to fraud or improper billing.

This applies to the following Programs and Years:

No. Facilities may not be mapped to a provider type unless an organization can demonstrate that all providers rendering services at the facility meet the NCQA provider definition defined in Appendix 3. Organizations should work with their HEDIS Compliance Auditor, who can review and approve mapping.

This applies to the following Programs and Years: