No. The organization only needs to consult with the treating practitioner when it is necessary to gather additional information. The consultation is not reviewed in the file review.
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10.15.2014 Clarifying text in UM 6 standard description Must the organization consult with the treating practitioner for every UM decision?
10.15.2014 NA for certification program Does WHP 13, Element E (which requires annual measurement of the effectiveness of two actions addressing improvement opportunities) apply to organizations previously certified in health appraisals or self-management tools under the HIP Standards and Guidelines?
10.15.2014
Annual Monitoring for Patients on Persistent Medications (MPM) The measure updates on page 43 of the MY 2014 P4P manual state that the numerator specifications for ACE/ARB, digoxin and diuretic rates no longer allow a blood urea nitrogen therapeutic monitoring test to count as evidence of annual monitoring.
On page 45, numerator specifications for ACE/ARB state, “At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year.”
Numerator specifications for digoxin state, “At least one serum potassium, at least one serum creatinine and at least one serum digoxin, and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year.”
Numerator specifications no longer allow a blood urea nitrogen test. Incorrect references to blood urea nitrogen therapeutic monitoring were inadvertently left in the P4P MPM measure specifications and should be removed. This update will be made in the December release of the MY 2014 P4P manual.
This applies to the following Programs and Years:
IHA P4P10.15.2014 Documentation requirements for Medicaid, Medicare and Marketplace product lines Under the 2015 Health Plan Standards and Guidelines, if an organization is bringing through its Medicare, Medicaid or Marketplace product line, what are the documentation expectations for the look-back period?
For certain elements with frequency or analysis requirements, (i.e., MEM 1 Element G; MEM 2 Element C; MEM 4 Element C; MEM 5 Element C; MEM 5 Element D; MEM 7 Element C, factors 3 and 5) the documentation requirement will be limited to a documented process for the Medicare, Medicaid and Marketplace product lines.
This applies to the following Programs and Years:
9.15.2014 General Guidelines In the draft MY 2014 P4P Manual published in September 2014, there is no mention of whether to apply a “14-day” rule to administrative data for numerators that require more than one service. It does mention to apply this rule in the new HbA1c 2 tests numerator for Diabetes Care. Should we apply this to CIS and HPV for P4P, as we will do for HEDIS 2015?
The “14 day” rule was added to the CDC specification because P4P had not adopted HEDIS 2015 General Guideline 44 for the September release of the MY 2014 P4P Manual. The guideline will be adapted for P4P and added to the final version of the MY 2014 P4P Manual, which will be released on December 1, 2014. This guideline, like HEDIS, will also apply to the CIS and HPV P4P measures, along with the Two HbA1c Tests indicator in the CDC measure.
This applies to the following Programs and Years:
IHA P4P9.15.2014 General Guidelines Should the change to the logic from HEDIS 2015 General Guideline 41 also be applied to IHA measures that require results from the most recent test?
Yes. HEDIS 2015 General Guideline 41 will be adapted for P4P and added to the final version of the MY 2014 P4P Manual, which will be released on December 1, 2014. The guideline, like HEDIS, will apply to the CDC HbA1c control indicators.
This applies to the following Programs and Years:
IHA P4P9.15.2014 Policies and Procedures: Accreditation status and Evaluation Option selection If a Marketplace product line is added to an existing product line through the automatic accreditation add-on process, when the Marketplace product line comes through again, what evaluation option will it be reviewed under, and what status will be available?
An NCQA-Accredited organization that received automatic accreditation via the Marketplace Add-On process may have the Marketplace product line reviewed against the First or Renewal Evaluation Option at the time of its Renewal Survey.
The organization must submit separate Survey Tools for an option other than a Renewal Survey.
The available accreditation statuses, elements reviewed and look-back periods are specified in the standards and guidelines for the selected Evaluation Option.
For First and Renewal Surveys, the accredited status is valid for up to 36 months.
This applies to the following Programs and Years:
9.15.2014
Evidence-Based Cervical Cancer Screening (ECS) The MY 2014 ECS update reads, “Clarified that the lower age threshold in step 3 of Rate 1, step 2 of Rate 2 and step 3 of Rate 3, to account for the look back period, should be 33 instead of 30.” Why does age 30 continue to be used in Rates 1, 2 and 3?
In the Administrative Specification, Rate 1, step 3 reads, “For women 30–65 years as of December 31 of the measurement year …”
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.
This applies to the following Programs and Years:
IHA P4P9.15.2014 Comprehensive Diabetes Care For the eye exam indicator, is documentation of hypertensive retinopathy treated differently from diabetic retinopathy? If there is documentation that a member was negative for hypertensive retinopathy in the year prior to the measurement year, is this compliant?
Although the two diagnoses are clinically different, hypertensive retinopathy is not treated differently from diabetic retinopathy for the CDC measure. The intent of the eye exam indicator is to ensure that members with evidence of any type of retinopathy have an eye exam annually, while members who remain free of retinopathy (i.e., the retinal exam was negative for retinopathy) are screened every other year. If it is clear that a retinal or dilated eye exam was performed by an eye care professional in the year prior to the measurement year and there is documentation indicating that the member is negative for hypertensive retinopathy, this can count as compliant.
This applies to the following Programs and Years:
HEDIS 20159.15.2014 PHQ: Evidence for seeking input from consumer representatives What evidence must an organization provide to meet the requirement for seeking input from consumer representatives?
The organization must provide a documented process for seeking and receiving input from consumers or consumer groups, and provide reports or materials showing that feedback was solicited and received.
The solicitation must address measures included in the program and how information about physicians is reported.
NCQA defines “consumers” as a non-health care professionals who have, or would, utilize health care services. NCQA defines “consumer groups” as organizations that advocate for people who are actual or potential users of health care services.
This applies to the following Programs and Years:
PHQ 20139.15.2014 Comprehensive Diabetes Care If a member is numerator negative for at least one indicator in the CDC measure, when may the optional exclusions be applied?
The optional exclusion criteria may be applied only if the member did not have a diagnosis of diabetes during the measurement year or the year prior to the measurement year. If the member was included in the measure based on claim or encounter data, as described in the event/diagnosis criteria, the optional exclusions do not apply because the member had a diagnosis of diabetes. If the member was included in the measure based on pharmacy data alone, the member may meet criteria for an optional exclusion if no diagnosis of diabetes was found in claim or encounter data or in the medical record.
For example, if a member was included in the measure based on pharmacy data but had a visit with a diagnosis of diabetes, the member does not meet optional exclusion criteria.
If a member was included in the measure based on pharmacy data alone and there was no claim or encounter with a diagnosis of diabetes, but medical record documentation indicated the member is a diabetic, the member does not meet optional exclusion criteria.
If a member was included in the measure based on pharmacy data alone and there was no claim or encounter with a diagnosis of diabetes and no evidence of diabetes in the medical record being reviewed, the member may meet optional exclusion criteria if there was a diagnosis of polycystic ovaries any time during the member’s history through December 31 of the measurement year, or a diagnosis of gestational diabetes or steroid-induced diabetes during the measurement year or the year prior to the measurement year.
This applies to the following Programs and Years:
HEDIS 20159.15.2014 Osteoporosis Management in Women Who Had a Fracture Step 4 states to exclude members who received a dispensed prescription or had an active prescription to treat osteoporosis during the 365 days (12 months) prior to the IESD. Define “active prescription.”
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.