An organization that does not have a voicemail system should have other means for identifying member calls after normal business hours, and return members’ call on the next business day.
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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9.10.2014 MEM: Clarifying after-hours response turnaround time for MEM3 Element B and MEM 5 Element B What is NCQA's expectation for organizations responding to calls after normal business hours for MEM 3, Element B and MEM 5, Element B?
8.18.2014 HP 2014 UM 8E: Federal guidelines and external reviews Does UM 8, Element E apply if an organization follows federal guidelines for external reviews?
Yes. If an organization informs NCQA that it follows the Affordable Care Act requirements for external reviews (PHS Act section 2719), UM 8, Element E applies, even if the state where the organization operates does not comply with federal regulations.
This applies to the following Programs and Years:
8.15.2014 Plan All-Cause Readmissions In the step 5 examples, how do you determine if an acute inpatient stay is excluded? In example 2, why is Stay 1 not excluded?
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.
This applies to the following Programs and Years:
HEDIS 20157.15.2014 Controlling High Blood Pressure Is a problem list in an office visit note considered undated?
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.
This applies to the following Programs and Years:
HEDIS 20155.20.2014 Supplemental Data Guidelines If a patient does not remember the exact date and location of a test or procedure, what is the minimum acceptable documentation for satisfying the supplemental data requirement for this measure? How specific does this information have to be? May member-reported data be entered into a legal health record by staff members?
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.
This applies to the following Programs and Years:
IHA P4P5.15.2014 Marketplace How will HEDIS work with the Marketplace products?
5.15.2014 MEM exception for members with no financial liability Is there an exception for MEM 3A and MEM 5A, factor 4 if members have no financial liability beyond a flat copay that is always the same fixed dollar amount and is specified on the organization’s Web site?
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.
This applies to the following Programs and Years:
4.22.2014 Notice for providing results Does a 45-day notice period apply when measurement is more frequent than annual (e.g., quarterly)?
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.
This applies to the following Programs and Years:
4.15.2014 Encounter Rate by Service Type (ENRST) We noticed some rate fluctuations this year and found that many of the laboratory/pathology procedure codes from the MY 2012 code tables were not included in the MY 2013 Value Set Directory. MY 2012 included CPT codes 80047-89398. This year, the codes only go up to 80076 and then skip to the 89xxx series. These changes are not documented in the VSD Summary of Changes. Should these codes be included in this year’s P4P reporting?
The December 2, 2013, release of the MY2013 P4P Value Set Directory (VSD) was incomplete for two value sets used to report the Encounter Rate by Service Type (ENRST) measure. Therefore, we are releasing a 2014-03-19 version of the VSD that contains the following changes:
· Laboratory and Pathology Services Value Set: Added 1331 CPT codes
· Radiology and Imaging Services Value Set: Added 21 CPT codes
The added codes can be identified in the VSD as follows:
· In the P4P Value Sets to Codes spreadsheet, set the filter in column C (Value Set Version) to “2014-03-19” to identify added codes.
· In the P4P Summary of Changes spreadsheet, set the filter in column F (Revised) to “2014-03-19” to identify added codes.
To access the correct value sets, go to the download center at https://downloads.ncqa.org/customer/Login.aspx and log in.
If you have any questions, contact p4p@ncqa.org.
This applies to the following Programs and Years:
IHA P4P4.15.2014 Distributing Information to Practitioners May an organization that does not contract with practitioners directly use a physician organization to distribute information?
4.15.2014 Outpatient Procedures Utilization – Percentage Done in Preferred Facility (OSU) In the MY 2012 specifications, in the step for counting total outpatient procedures both Option A and Option B allowed both POS and UB Type of Bill codes. In the MY 2013 specifications, it appears that Option A only allows POS codes and Option B only UB Type of Bill codes. Is this change intentional?
Thank you for bringing this to our attention. When converting coding table references to value set references, the Option A UBTOB language and Option B POS language was inadvertently omitted. For OSU, Options A and B should include both POS and UB Type of Bill codes and should read as follows:
Any of the following code options meet criteria:
· Option A: Ambulatory Surgery Option A Value Set with Ambulatory Surgery POS Value Set .
· Option A: Ambulatory Surgery Option A Value Set with Ambulatory Surgery UBTOB Value Set.
· Option B: Ambulatory Surgery Procedure Value Set with Ambulatory Surgery UBREV Value Set and Ambulatory Surgery UBTOB Value Set.
· Option B: Ambulatory Surgery Procedure Value Set with Ambulatory Surgery UBREV Value Set and Ambulatory Surgery POS Value Set.
This will be corrected in the next release of the manual.
This applies to the following Programs and Years:
IHA P4P4.15.2014 HEDIS and ICD-10 The ICD-10 implementation date has been delayed. Will NCQA include ICD-10 codes in HEDIS 2015?
No. Because of the delay in ICD-10 implementation, ICD-10 codes will not be used during the HEDIS 2015 measurement year (the 2014 calendar year) and therefore will not be included in the HEDIS 2015 Value Set Directory.
Purchasers of HEDIS 2015 technical specifications will receive a separate file with ICD-10 codes proposed for inclusion in future releases of HEDIS, but the codes will not be considered part of the 2015 measure specifications.