No. To be considered a direct transfer, the admission date for the second stay must be on the same date of service or one day after the discharge date from the first stay.
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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9.15.2016 Direct Transfers In a “direct transfer,” the discharge date from one inpatient setting and the admission date to a second inpatient setting are one calendar day apart or less. May the admission date from the second inpatient setting take place on the day before the discharge date from the first setting?
9.15.2016 ED/Observation Visits Resulting in an Inpatient Stay Many measures instruct organizations to not include ED visits or observation visits that result in an inpatient stay. The ED visit or observation visit results in an inpatient stay when the ED/observation date of service and the admission date for the inpatient stay are one calendar day apart or less. May the inpatient admission take place on the day before the ED or the observation visit date?
9.15.2016 Mapping Facilities to Provider Types May an organization map a facility to a provider type for reporting HEDIS measures (e.g., map a Federally Qualified Health Center [FQHC] to the type Primary Care Practitioner (PCP))?
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:
HEDIS 20178.15.2016 Scope of Review in NET 3, Elements B and C The scope of review was updated in NET 3, Elements B and C in the July release of the NCQA Corrections, Clarifications and Policy Changes to the 2016 HP Standards and Guidelines. Was this update correct?
No. A third paragraph should have been added that reads, “For factor 2, NCQA reviews a documented process, reports or materials, depending on the action taken to address identified opportunities.”
The update was intended to give organizations the option of presenting its updated policies and procedures, materials or a report showing revisions, if the intervention was revision of policies and procedures or materials.
NCQA will correct the scope of review for both elements in the November release of the NCQA Corrections, Clarifications and Policy Changes to the 2016 HP Standards.
This applies to the following Programs and Years:
8.04.2016 Updated: Documentation for structural requirements when delegating to an NCQA-Accredited MBHO What are the documentation requirements for a health plan delegating a structural requirement to an NCQA-Accredited MBHO?
Health plans that delegate the following structural requirements to an NCQA-Accredited MBHO are eligible to receive automatic credit, as stated in Appendix 5, Table 3 (this is Appendix 3, Table 21 in the MBHO standards and guidelines), if they meet the criteria for automatic credit. The organization does not need to provide its own documentation.
- QI 1, Element A: Program Structure, factor 2 (MBHO QI 1, Element A, factor 3).
- QI 4, Element B: Behavioral Healthcare Telephone Access Standards (MBHO QI 5, Element B).
- NET 1, Element D: Practitioners Providing Behavioral Healthcare, factors 1–3 (MBHO QI 4, Element B, factors 1–3).
- NET 2, Element B: Access to Behavioral Healthcare, factors 1–3 (MBHO QI 5, Element A, factors 1 and 2).
- UM 1, Element A: Utilization Management Structure, factors 2 and 4 (MBHO UM 1, Element A, factors 1 and 2).
- UM 1, Element C: Behavioral Healthcare Practitioner Involvement (UM 1, Elements A and B).
1MBHO equivalent standard/element is in parentheses.
This applies to the following Programs and Years:
8.04.2016 Updated: Documentation for structural requirements when delegating to an NCQA-Accredited health plan What are the documentation requirements for a health plan delegating a structural requirement to an NCQA-Accredited health plan?
Organizations that delegate the following structural requirements to an NCQA-Accredited health plan are eligible to receive automatic credit, as stated in Appendix 5, Table 2, if they meet the criteria for automatic credit. The organization does not need to provide its own documentation.
· QI 4, Element B: Behavioral Healthcare Telephone Access Standards.
· QI 5, Element F: Case Management Process.
· NET 1, Element B: Practitioners Providing Primary Care, factors 1 and 2.
· NET 1, Element C: Practitioners Providing Specialty Care, factors 1–4.
· NET 1, Element D: Practitioners Providing Behavioral Healthcare, factors 1–3.
· NET 2, Element A: Access to Primary Care.
· NET 2, Element B: Access to Behavioral Healthcare.
This applies to the following Programs and Years:
7.15.2016 Standardized Healthcare-Associated Infection Ratio Will NCQA post an example HAI Standardized Infection Ratio (SIR) table to be used when reporting the Hospital Acquired Infection (HAI) measure?
Yes. NCQA posted an example HAI SIR table to the HEDIS 2017 Web site at http://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017. The final HAI SIR table (Table HSIR) will be posted to the NCQA Web site by January 2, 2017.
This applies to the following Programs and Years:
HEDIS 20176.15.2016 Collecting data by practitioner prescribers and non-prescribers Must an organization collect access data by practitioners who prescribe and those who do not prescribe to meet all factors in NET 2, Element B?
5.20.2016 UM 4, Element H File Review Does UM 4, Element H file review include benefit denials that resulted from the UM medical necessity review process?
Yes. If an organization inadvertently includes a benefit denial in the UM 4–UM 7 medical necessity denial file reviews, NCQA verifies that the file is appropriately classified as a benefit denial. If so, NCQA scores the file NA. If not, NCQA reviews the files under the medical necessity denial requirements of UM 4–UM 7.
This applies to the following Programs and Years:
UM-CR 20165.20.2016 UM 4, Element H File Review and Medical Necessity Denials Are medical necessity denials included in the UM 4, Element H file review?
No. If an organization inadvertently includes a medical necessity denial in the UM 4H benefit denial file review, NCQA verifies that the file is appropriately classified as a medical necessity denial. If so, NCQA scores the file NA. If not, NCQA reviews the files under the benefit denial requirements of UM 4H.
This applies to the following Programs and Years:
UM-CR 20164.15.2016 State restrictions on information provided to prospective members and RR 5 If an organization can provide only certain information to prospective members, due to regulatory restrictions, and that information does not cover some requirements in RR 5, how does NCQA score the unmet requirements?
4.15.2016 Product line requirement for QI 4, Element E What evidence must organizations present to meet QI 4E?
For factor 1, organizations present a report of complaints and appeals by product line.
For factor 2, organizations present a report showing member experience results by product line. Organizations are not required to conduct a separate survey for each product line brought forward. If organizations conduct one behavioral healthcare survey across all product lines, results must be presented by product line, even if response rates are low.
