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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12.15.2015 Update on Marketplace Measure Scoring Policy for Accreditation How will Marketplace product lines be scored for 2016?

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:

12.15.2015 PQRS Codes for HEDIS Reporting Physician Quality Reporting System (PQRS) includes CPT Category II codes and HCPCS codes, some of which are not included in the HEDIS value sets. May organizations map these codes for use in HEDIS reporting?

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:
HEDIS 2016

12.15.2015 Audit Designations in 2016 WHP Reporting Tool Will the 2016 WHP Reporting Tool be updated to reflect the new audit designations included in HEDIS 2016 Volume 2?

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:
HEDIS 2016

12.02.2015 P4P Value Set Directory Were there any changes in the December 1, 2015 release of the P4P VSD that are not listed in the Summary of Changes spreadsheets?

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:
IHA P4P

11.16.2015 Risk-Adjusted Measures There are duplicate diagnosis codes in the following tables used for risk adjustment: PCR-DischCC and CC-Comorbid. Is this correct?

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:
HEDIS 2016

11.16.2015 Relative Resource Use for People With Asthma Will NCQA publicly report the Relative Resource Use for People With Asthma (RAS) measure for the Medicare product line for HEDIS 2016?

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:
HEDIS 2016

11.16.2015 Administrative-only Measures For administrative-only measures such as Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART), may organizations abstract medication information from the medical record to identify numerator hits?

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:
HEDIS 2016

10.15.2015 Off-Marketplace in Accreditation If Off-Marketplace plans are not required by CMS to be in QRS, are they still required to include their membership in commercial product line when submitting for health plan accreditation?

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:

10.15.2015 Oral notification of expedited appeal decisions UM 5 allows organizations to provide initial oral notification for urgent requests, with written notification within three calendar days. Does this also apply to expedited appeal decisions in UM 9, Element B?

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

This applies to the following Programs and Years:
UM-CR 2013

10.15.2015 Childhood Immunization Status When abstracting medical record data for the hepatitis B vaccine, must the rules for the newborn hepatitis B vaccination in the administrative specification be followed?

When abstracting hepatitis B vaccine data from the medical record, there is no requirement that one be a “newborn” vaccine specifically, and there are no date restrictions. For hybrid reporting, when all events come from the medical record, documentation of three hepatitis B vaccines administered on three different dates of service meets criteria.

The newborn hepatitis B vaccine instructions and value set are intended to be used only for administrative data. The rules for the newborn hepatitis B vaccine are in place because the code in the Newborn Hepatitis B Vaccine Administered Value Set is a generic code that indicates a vaccine was administered but it does not indicate which vaccine was administered (it is not specific to hepatitis B). If this code occurs during the eight-day period (date of birth plus 7 days) then it is appropriate to assume it was a hepatitis B vaccine that was administered (since this is the only vaccine that is routinely administered to all children before discharge from the hospital).

This applies to the following Programs and Years:
HEDIS 2016

10.15.2015 Delegation revocation and documentation If an organization revokes delegation, may the organization receive “NA” scoring if the delegate does not provide the necessary documentation?

No. The organization is responsible for meeting NCQA requirements even if it terminates the delegation agreement. 

This applies to the following Programs and Years:

10.15.2015 P4P Overview In the draft version of the MY 2015 Value Based P4P Manual released on 9/1/2015, page 6 indicates that the PO deadline for supplemental data collection is February 15, 2016, and the supplemental data validation deadline is March 15, 2016. Under the Supplemental Data Validation Deadline Activity, the last sentence states “Primary source verification (PSV) for member-reported and nonstandard supplemental data must not occur prior to March 2 unless the organization finished all supplemental data processes, collection and entry.”
Should the last sentence be updated to say February 15 instead of March 2?

Yes, you are correct; the date in the last sentence under Supplemental Data Validation Deadline should state:

“Auditor finalizes approval of all supplemental data. Primary source verification (PSV) for member-reported and nonstandard supplemental data must not occur prior to February 15 unless the organization finished all supplemental data processes, collection and entry.”

We will update this for the final version of the MY 2015 Value Based P4P Manual, released on December 1, 2015.

This applies to the following Programs and Years:
IHA P4P