FAQ Directory

Organizations seeking accreditation or certification in UM under the 2016 standards may receive automatic credit for updating delegation agreements prior to survey tool submission, to include:

• The new pharmacy requirements (UM 5, Elements E and F; UM 6, Element C; and UM 7, Elements G–I included in the 2016 Standards and Guidelines for the Accreditation of Health Plans) as delegated activities.
• The requirement for delegates to provide separate UM pharmacy files for review.

Updates may be made to the delegation agreement, to an addendum or in other binding communication between the organization and the delegate. 

This applies to the following Programs and Years:

No. The Marketplace product line is specifically for use with QRS reporting. There are differences between the HEDIS for the Quality Rating System and Volume 2 measure specifications. General Guideline 1 of the HEDIS for the Quality Rating System publication specifically states that QRS measure data must be collected separately for the Marketplace population. Future versions of the HEDIS for the Quality Rating System publication will only list the Marketplace product line. For those reporting on other product lines, the HEDIS Volume 2 publication must be used. 

This applies to the following Programs and Years:

For 2016, NCQA will continue to score Marketplace product lines only on the Accreditation standards; however, whether an organization is currently accredited or plans to earn accreditation in 2016, NCQA will ascertain whether it continues to be a Qualified Health Plan under CMS requirements. If the organization is not listed on Healthcare.gov because it did not submit Quality Rating System (QRS) measures to CMS, its accreditation will be revoked. Prior to revocation, NCQA will discuss the issue with the organization. There may be circumstances where an organization is not required by CMS to report QRS measures. The organization would still be listed on Healthcare.gov and would be considered to meet NCQA requirements.
 
If your organization has any questions about this policy, please send them through the Policy Clarification System (PCS) at https://my.ncqa.org/ .

This applies to the following Programs and Years:

Yes. The W15 measure does not have exclusions and this data element was included in error. It will be deleted in future publications.

This applies to the following Programs and Years:

No. Because CPT Category II codes and HCPCS are standard codes they are not eligible for mapping (the value sets include all standard codes that have been identified as appropriate for use in HEDIS reporting). The Category II and HCPCS codes included in PQRS measures were created specifically for use in PQRS reporting and are not appropriate for use in reporting HEDIS measures. If a service or procedure was rendered by a provider, the expectation is that the provider will submit a claim to the health plan for the service or procedure; the codes expected to be on the claim are included in the HEDIS value sets and identify the member for the HEDIS measure.

This applies to the following Programs and Years:

No. The WHP 2016 Reporting Tool audit designations will not be updated because the tool and specifications were released prior to these changes. Organizations should report WHP measures for 2016 using the existing WHP Reporting Tool. Any updates will be included in the 2017 WHP Reporting Tool, which will be released on March 31, 2016.

This applies to the following Programs and Years:

Yes. The following changes were made and were not listed in the Summary of Changes spreadsheets.

• In the Acute Conditions value set, diagnosis codes that starts with a V were mislabeled “ICD9PCS.” The label was changed to “ICD9CM.”
• In the Potentially Planned Procedures value set, the ICD9 procedure codes were mislabeled “ICD9CM.” The label was changed to “ICD9PCS.”

This applies to the following Programs and Years:

For administrative-only measures, information abstracted from the medical record is considered nonstandard supplemental data and is subject to all requirements described in General Guideline 34. The supplemental data must include all data elements required by the measure specification. For pharmacy data, this means that all data elements from the NDC lists must be present: the generic name, strength/dose, route and date when the medication was dispensed to the member. Generic documentation in the medical record (e.g., that a patient “was prescribed” or “is taking” a medication) that does not include drug name, strength/dose and dispense date does not meet criteria.

This applies to the following Programs and Years:

Yes. The risk adjustment measures are based on the CMS Hierarchical Condition Categories (HCC) risk-adjustment methodology. The updates made to the model, combined with the addition of ICD-10 diagnosis codes, changed the way clinical conditions (CCs) are assigned. When there is a duplicate diagnosis code, it is assigned to multiple CCs. For example, ICD-10 diagnosis code I132 should be mapped to both CC-85 and CC-136. Therefore, CC-85 and CC-136 should both be used towards calculating comorbid weight. In addition, for the Plan All-Cause Readmissions measure, it is possible for members to have more than one discharge CC if the primary discharge diagnosis is assigned multiple CCs.

This applies to the following Programs and Years:

No. Due to the addition of the Medicare product line to the RAS measure, this measure will not be publicly reported for the Medicare product line for HEDIS 2016. The commercial and Medicaid product lines for RAS will continue to be publicly reported for HEDIS 2016.

This applies to the following Programs and Years:

Yes, Off-Market plans are required to be in the commercial product line when submitting for health plan accreditation.

This applies to the following Programs and Years:

Yes. Organizations may provide oral notification, followed by written/electronic notification within three calendar days.

This applies to the following Programs and Years: