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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3.15.2015 Eligibility for Automatic Credit Is an organization eligible for automatic credit if its accredited delegate has a single practitioner network with centralized credentialing (i.e., one credentialing committee; the same staff handle all practitioner credentialing) for all product/product lines, but is not accredited for the delegated product line?

Yes. Because the organization uses the same practitioner network for all product/product lines, and all practitioners are subject to CR file review during an NCQA Accreditation Survey, the file is eligible to receive automatic credit. This is an exception to the Product Match policy posted on Policy Updates page.

This applies to the following Programs and Years:

3.15.2015 HEDIS Reevaluation Does the new 2015 HPA annual HEDIS evaluation policy apply to organizations surveyed on or before June 30, 2015?

No. Organizations with submissions before July 1, 2015, are reevaluated on the HEDIS measures in effect at their last survey. Organizations submitting after June 30, 2015, are reevaluated on the HEDIS measures in effect for that reporting year.

This applies to the following Programs and Years:

3.13.2015 Meaningful Use of Health IT An FAQ about e-measure reporting posted on 1/29/15 states, “You should use the same definition of PCP as outlined in the NPI data file specification instructions. Providers in your denominator should include employed and contracted PCPs (MD or DO) in the following specialties: Family/General Practice, Internal Medicine and Pediatrician/Adolescent Medicine.”
The Controlling High Blood Pressure e-measure is specified for members 18 years and older, should pediatricians be excluded from the denominator?

POs have the option of excluding pediatricians from the Controlling High Blood Pressure e-measure denominator.

This applies to the following Programs and Years:
IHA P4P

3.13.2015 Proportion of Days Covered by Medications (PDC) An answer to an FAQ posted on 2/17/15 states, “Exclude members whose ESRD diagnosis is noted any time during the measurement year.”
The MARx System output, which contains the RxHCC codes, does not release the entire 2014 dates of service until after the IHA reporting deadline. Does the FAQ apply to both the RxHCC and ICD-9-CM code?

The intent is to use the most current information for the ESRD exclusion. If ICD-9-CM is used, then any code from the value set during the measurement year excludes the member from the denominator. If the MARx System output is used, then the most recent version applies. Although the time frames are not consistent between ICD-9-CM and RxHCC, it is the most current information to identify patients with ESRD. ICD-9-CM is preferred, but if it is not available, the most current MARx System output can be used.

This applies to the following Programs and Years:
IHA P4P

3.13.2015 High Risk Medication (HRM) According to the last paragraph on page 149, plans and POs should use the first two prescription fills to calculate average daily dose to determine numerator compliance. Should other fills during the treatment period be considered when calculating average daily dose?

Yes, all fills during the treatment period should be considered. Calculate the average daily dose for each High-Risk Medication fill using the formula (quantity dispensed x dose)/(days supply). If the average daily dose for any two fills of the HRM exceed the threshold, then the member is numerator compliant.

This applies to the following Programs and Years:
IHA P4P

2.26.2015 Relative Resource Use for People With Diabetes In the Quality Ratings System (QRS) Measure Technical Specifications, the RRU General Guidelines reference 13 risk groups, but there are only 8 risk groups referenced in Table RDI-B-4: Data Elements for Relative Resource Use for People With Diabetes. Which is correct?

Table RDI-B-4 should include all 13 risk groups, to match the RRU General Guidelines in the QRS technical specifications.

This applies to the following Programs and Years:
Exchange 2015

2.17.2015 Controlling High Blood Pressure for People with Hypertension (CBPH) In the Controlling High Blood Pressure for People with Hypertension specifications, there are three rates in the description. In the clinical file layouts, only one rate is included. Is this intentional?

No. The two additional rates were inadvertently left out of the clinical file layouts. Three rates should be reported for this measure:

  • The percentage of non-diabetic members 18-59 years with a diagnosis of hypertension whose blood pressure was adequately controlled (<140/90 mm Hg) during the measurement year.
  • The percentage of non-diabetic members 60-85 years with a diagnosis of hypertension whose blood pressure was adequately controlled (<150/90 mm Hg) during the measurement year.
  • The total rate.

Revised Clinical File Layouts have been posted for health plans and physician organizations (http://iha.org/manuals_operations_2014.html), to reflect this change.

This applies to the following Programs and Years:
IHA P4P

2.17.2015 Proportion of Days Covered by Medications (PDC) The DTX and PDC measures include a denominator exclusion for ESRD status. Does the status need to be “any time in the member's history,” or just during the measurement year?

Exclude members whose ESRD diagnosis is noted any time during the measurement year.

This applies to the following Programs and Years:
IHA P4P

2.17.2015 Proportion of Days Covered by Medications (PDC) The ESRD Value Set includes the code RxHCC 121. Is the RxHCC code system new? Where is this type of code found?

Yes, the RxHCC code system and code were added to the Value Set Directory when we created the ESRD Status Value Set. This code is used to identify patients with ESRD for the denominator exclusion in Diabetes: Appropriate Treatment for Hypertension and Proportion of Days Covered by Medications.

The RxHCC code can be found in the CMS Medicare Advantage and Prescription Drug System (MARx), which provides a monthly report of members’ RxHCCs to plan sponsors. For MY 2014, use the 2013 model software of the RxHCC system. 

This applies to the following Programs and Years:
IHA P4P

2.17.2015 Evidence Based Cervical Cancer Screening (ECS) The service date example in Rate 2, step 2 states, “If the service date for cervical cytology was November 27 of the measurement year, the HPV test must include a service date on or between December 1 and December 5 of the measurement year.” This does not align with the other service data examples in Rate 1 and Rate 3 of the Administrative Specifications. Should the service dates in Rate 2, step 2 align with the other examples?

Yes. The service date example in Rate 2, step 2 should align with the examples in Rate 1 and Rate 3. The dates were inadvertently switched in the Rate 2 example and should state:

“For example, if the service date for cervical cytology was December 1 of the measurement year, the HPV test must include a service date on or between November 27 and December 5 of the measurement year.”

This applies to the following Programs and Years:
IHA P4P

2.15.2015 Use of credentialing and recredentialing verification to meet factor 3 For QI 12, Element A, factor 3, do verification activities conducted during the initial credentialing and recredentialing process count as quality measures?

CR 3–CR 6, credentialing verification activities do not count as quality measures for QI 12, Elements A and B. However, an organization may receive credit if its credentialing process incorporates clinical quality measures from NCQA (or other accreditors), the National Quality Forum (NQF), national medical boards (ABMS or AOA) or other quality measurement development sources. The organization may also incorporate member experience and cost-related measures into the credentialing process.

This applies to the following Programs and Years:

2.15.2015 Negative inferences of stating quality, experience or cost is not measured for practitioners and hospitials For QI 12, Element A, factor 3 and Element B, factor 2, did NCQA consider the negative inference of requiring an organization to state that it does not use quality, member experience or cost-related measures when selecting practitioners or hospitals to participate in its network?

Yes. The intent of this requirement is to provide consumers with quality information about Marketplace Silver Plans in order to help them make a better informed choice during enrollment. Therefore, organizations to be transparent about whether they used quality, member experience or cost-related measures when selecting practitioners or hospitals to participate in its networks.

This applies to the following Programs and Years: