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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1.15.2016 Specificity of the Notification of Information Availability For elements that require information to be distributed to members or practitioners (e.g., QI 2, Element B; RR 3, Element A), how detailed must the notice of availability of information on the organization’s Web site be?

The notice does not have to include the posted information verbatim, but must include a description specific enough to give readers a clear idea of the topic and the general content, and must include a link to the information. The organization may group or summarize the information by theme.
EXAMPLES: 
For QI 2, Element B, the notification could state, “Information on our QI program description, including goals and achievements, is available on our Web site at [URL]…” For RR 3, Element A, the notification could state: “We have posted information on our Web site [URL] that will help you understand the benefits and services covered in your benefits plan; plan restrictions; how to obtain health care services and medications; how to file a claim for payment (if needed); how submit a complaint; how to appeal an adverse decision; and how [organization] evaluates new technology.”

This applies to the following Programs and Years:

1.15.2016 Comprehensive Diabetes Care The urine protein testing requirements for the Medical Attention for Nephropathy indicator were revised. Some examples in HEDIS 2015 (e.g., urine dipstick) are not listed in the 2016 specifications, so do urine dipsticks and test strips still meet criteria for this indicator for HEDIS 2016?

Yes. As a result of changes to the measure, the two example lists were combined into a single list to remove redundancy. All examples that met criteria in HEDIS 2015 meet criteria for HEDIS 2016. Urine dipsticks are considered “spot urine” tests so they meet criteria based on the example, “Spot urine for albumin or protein.”

This applies to the following Programs and Years:
HEDIS 2016

1.15.2016 Care for Older Adults Are CMS Medicare-Medicaid Plans (MMPs) required to report the SNP-only measure, Care for Older Adults (COA), for HEDIS 2016?

Yes. According to the CMS HEDIS 2016 reporting requirements memo, MMPs are required to report all measures in Table 3. This includes COA, even though it is referenced as being SNP-only.

This applies to the following Programs and Years:
HEDIS 2016

1.15.2016 Statin Therapy for Patients With Cardiovascular Disease and Statin Therapy for Patients With Diabetes Are all members who are numerator compliant for Rate 1 used as the eligible population for Rate 2 in the Statin Therapy for Patients With Cardiovascular Disease (SPC) and Statin Therapy for Patients With Diabetes (SPD) measures?

Yes. All members who are numerator compliant for Rate 1 must be used as the eligible population for Rate 2 in both the SPC and SPD measures (regardless of the data source used to capture the Rate 1 numerator). For example, if supplemental data were used to identify compliance for the Rate 1 numerator, then supplemental data will be included in identifying the Rate 2 eligible population.

 

If pharmacy data are the source data, and are treated similar to encounter data, they could be classified as encounter data rather than as supplemental data. For example, if a pharmacy benefit manager (PBM) offers the pharmacy benefit on behalf of a health plan and regularly sends pharmacy data to the plan in a standard format, the data could be considered to be encounter data. Organizations must work with their auditor to determine how data are classified. The auditor will review the organization’s pharmacy benefit structure and the processes for receiving and using data when determining the classification.

This applies to the following Programs and Years:
HEDIS 2016

1.15.2016 Use of Multiple Concurrent Antipsychotics in Children and Adolescents May we use supplemental data to report the Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC) measure?

No. Because supplemental data may not be used to identify the eligible population, and the same events are used for the denominator and numerator in APC, supplemental data may not be used for this measure. The data elements table in Volume 2 for APC inadvertently includes the “Numerator events by supplemental data” data element. This field will not be included in the IDSS.

This applies to the following Programs and Years:
HEDIS 2016

12.18.2015 HEDIS for the Quality Rating System Can organizations use the HEDIS for the Quality Rating System publication to report product lines other than Marketplace?

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:
Exchange 2016

12.18.2015 Automatic credit for UM pharmacy elements May health plans receive automatic credit for the new UM pharmacy elements if they delegate to organizations accredited or certified under standards years prior to 2016?

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:
UM-CR 2016

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 Well-Child Visits in the First 15 Months of Life (W15) The Data Elements table for the W15 measure includes a field for required exclusions. Is this a mistake?

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:
Exchange 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

12.15.2015 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

12.02.2015 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