Generally, ER denials are not included in the universe of files for initial UM decisions unless a denial is appealed. In that case, the ER appeal is included in the universe of files for appeals.
UM-CR 2013
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.
PQ 3A factors 3-5 and PQ 3B are scored NA if the organization does not display physician performance information for the pay-for-performance program.
PQ 3 C and D are scored against the pay-for-performance requirements if the organization has one complaint process for all programs. If the organizations complaint process is program-specific, PQ 3C and D are scored NA for the pay-for-performance program. NCQA scores PQ 4B factor 1 and the customer portion of factor 4 NA for the pay-for-performance program.
Because there is no NA scoring option in PQ 3B, 3C and 4B, these requirements are scored yes for pay-for-performance programs described above until the NA scoring option is added during the 7/29 release of the ISS tool.
PHQ 2013
The NSC is not recognized by NCQA as a source for education and training. However, the NSC would be considered an agent of the medical or professional school if the school has a contract with the Clearinghouse to provide verification services. The organization must provide documentation that the specific school has a contract with the Clearinghouse.
UM-CR 2013
No. Indacteral was removed from the ASM-C NDC list and noted in a Word document posted with the NDC lists on November 2, 2012. The medication was reviewed by the HEDIS Expert Pharmacy Panel and determined to be not indicated for asthma, so it was removed from the measure. The MY 2013 P4P manual will reflect this change.