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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IHA 2014
An “active prescription” means that a member has a surplus of medication to take from a prescription dispensed previously. Therefore, in step 4 (required exclusions), the member is excluded if a prescription was dispensed during the 12 months prior to the IESD, or prior to that time frame if the member has remaining pills to take in the 12 months prior to the IESD.
HEDIS 2015
The age band for this measure was not changed; the language and age referenced in the steps were clarified to account for the look-back period. For the steps pertaining to the cervical cytology and HPV co-tests, because a woman must have been “30 years or older on the date of both tests,” and the tests must have been performed in the third or fourth year prior to the measure year, look only at women 33 and older.
This change was inadvertently left out of Rate 1, step 3. The final release of the MY 2014 P4P Manual on December 1, 2014, will contain the correct language.
For the descriptions of Rates 1, 2 and 3, however, the age bands have not changed; the measure aligns with current guidelines and looks at women 30–65 years of age.
IHA 2014
To determine if a stay should be excluded, identify the index hospitalization and the FIRST readmission (if there is one). If the FIRST readmission was planned for, drop the index.
So, for example 2:
Stay 1. Index hospitalization with unplanned readmission (stay 2): Include as index.
Stay 2. Index hospitalization with planned readmission (stay 3): Drop as index.
Stay 3. Index hospitalization with planned readmission (stay 4): Drop as index.
Stay 4. Index hospitalization with no readmission: Include as index.
Stay 1 is the index. Stay 2 is the first readmission to assess, but because it does not meet criteria for a “planned hospital stay,” stay 1 is not excluded.
HEDIS 2015
No, if a problem list is found in an office visit note then it would be considered a dated problem list and the date of the visit must be used. A true problem list is a standalone document in the medical record that records a member’s conditions. It is typically located in a centralized section of the medical record (usually the front of the chart) and lists all diagnoses. In an EHR a problem list is present at all routine office visits.
If the documentation is part of the member’s medical history, progress note or office visit note, the date of the visit must be used as the date of the HTN confirmation and must be on or before June 30 of the measurement year. The representative BP reading must occur after the date when the diagnosis of HTN was confirmed.
HEDIS 2015
General Guideline 28 outlines the requirements for using member-reported supplemental data, which may be accepted only when accompanied by proof-of-service documentation from the legal health record. If proof-of-service documentation is not available, member-reported information on services rendered (patient history) are acceptable only if taken by a PCP as part of the member’s history. Information must be signed, dated and maintained in the member’s legal health record. General Guideline 29: Date Specificity addresses measures that include date requirements in order to achieve numerator compliance. Dates must be specific enough to determine that the event occurred during the period specified by the measure.
IHA 2013
Yes, if the flat copay amount is specified on the organization’s Web site. Members must have no additional financial liability (i.e. co-insurance, deductibles, charges in excess of allowed amounts, differentials in cost between in-network care and out-of-network care, costs that vary for the formulary) for services and cannot be balance-billed by a practitioner, provider or other party.
This exception does not apply to Element B in MEM 3 and 5.
Yes. The 45-calendar day notice period for providing results and providing an opportunity for a physician to request a correction or change applies to each cycle of measurement and action an organization takes, regardless of frequency (e.g., biannual, annual, semiannual, quarterly); however, if an organization recalculates results without changing its methodology or measures, it does not need to provide the methodology again as long as it supplies information on how to obtain that methodology.
The exception to the minimum 45-calendar-day notice period for action is when the action involves only pay-for-performance activities that are not publicly reported (e.g., an action that is only between the organization and the physician). In this instance, the organization may provide the results and methodology concurrent with additional or bonus payment. It must still provide a process for the physician to request corrections or changes.
