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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1.16.2013 Medical Record Review Validation If a plan has one failed medical record during MRR validation, and a second sample also fails, do the measure and all the measures in that group receive an NR?

If a plan fails the test – one error in each of two samples – and cannot correct the error and resubmit the correction to the auditor, the plan may not use the Hybrid Method for reporting that measure. The plan can report the administrative rate or report an NR for that measure. The auditor must determine whether the error affects all the other measures in the group and their reportability.

HEDIS 2013

1.16.2013 General Guidelines Can Health plans collect data from charts for a supplemental database and use the results for administrative rates?

Looking at charts is one way to collect data for a supplemental database (note: this activity should be distinguished from and not include chart review activities for the hybrid measures). All data in the supplement database, regardless of how it was collected, should be treated as administrative data. With the exception of standard data sources such as EHRs and state registries, supplemental databases should not be used during chart review for the hybrid measures.

HEDIS 2013

1.16.2013 Medical Record Review Validation For measures that are heavily or entirely reliant on MRR data (e.g., COA, ABA, WCC, CDC BPs), if an organization attempts MRR validation and fails, or is able to retrieve a only small percentage of charts, can they report an administrative rate as low as 0% (assuming no other issues are identified)?

A low administrative rate, even 0%, can be reported, if the plan wants to submit such a rate and the auditor finds no bias or other problems in the administrative process.

HEDIS 2013

1.16.2013 General Guidelines Is there a deadline for updating administrative rates with new sources of supplemental data?

Yes, the December Update included a modification to the audit timeline that requires all supplemental database activities be concluded by 5/1 in the reporting year. NCQA requires this deadline to allow sufficient time for audit review and possible corrections. The update should be made in the HEDIS Audit Timeline in Volume 5, on page 52 and in Volume 2, on page 17. This sentence should be added: "Auditor finalizes approval of Supplemental Databases, policies, procedures, and content (data)." by May 1.

HEDIS 2013

1.16.2013 Comprehensive Diabetes Care (CDC) Can CPT Category II code 4010F be used to identify ACE inhibitor/ARB therapy for the Medical Attention for Nephropathy indicator?

Yes. CPT Category II code 4010F (ACE inhibitor or ARB therapy prescribed or currently being taken) may be used to identify ACE inhibitor/ARB therapy (Table CDC-N) for the Medical Attention for Nephropathy indicator for P4P MY 2012. This code will be added to the MY 2013 manual.

1.16.2013 Medical Record Review Validation Can auditors provide plans with the measures selected for over-read earlier than May 1? What if the plan finishes MRR earlier?

The current timeline says that the auditor selects the measures for review on May 1 and not before; however, if the auditor reviews the health plans internal timelines, and finds that the plan expects to finish MRR early, it is acceptable that the auditor send the measure list when all chart review is complete and he has received a final count of numerator hits for each hybrid measure. For example, if the plan finishes all chart chases on April 29 and provides the numerator count lists, the auditor can select the measures for validation and start the process early.

Note: If the auditor allows for an earlier MRRV timeline, the plan may have to adjust other deadlines affected by this change.

HEDIS 2013

1.16.2013 General Guidelines Are home-test kits that collect biometric values allowed for HEDIS reporting?

Only tests administered by a qualified provider may be used for HEDIS reporting. Self-administered tests (including home-test kits) where the patient performs the test and obtains the result are not eligible for use in HEDIS reporting.

Results from a home test kit where a qualified provider uses the kit to conduct a test or determine the results in the office are eligible for HEDIS reporting. If any home test is billed by a qualified provider using a code specified in the measure, it is eligible for use in HEDIS reporting; the code alone indicates compliance.

HEDIS 2013

1.16.2013 All-Cause Readmissions (PCR) The MY 2012 P4P manual states that the All Cause Readmission measure will be collected as part of Medicare and is a mandatory testing measure for P4P, but this measure is not listed on the IHA Web site in the MY 2012 measure set.

Although P4P will collect the All Cause Readmission measure from health plans as part of the regular P4P clinical submission process, technically, it is an Appropriate Resource Use measure. As such, it is listed as a testing measure in the Appropriate Resource Use section. Note: Only health plans will submit results for this measure.

1.16.2013 Medical Record Review Validation If during MRR validation, a plan fails two samples, and informs the auditor they corrected the problem, what follow-up items are required to validate that the corrections were appropriate?

The auditor may use one or more methods to validate the chart error corrections. Follow-up actions should include:
· reviewing the error investigation and results
· reviewing policies and procedures to correct the error
· reviewing the corrected sample to ensure the updated numerator counts are correct and performing final hybrid rate review
· re-sampling charts for a new validation

Examples:

1. For the exclusions or data errors in the diabetes measure records, the auditor identified a pattern: she found two cases where the chart reviewer said the members did not have diabetes, but the chart showed that both members had elevated blood sugars and above average HbA1c results. One member had a PCP diagnosis of metabolic syndrome that placed him in the measure. The other member had a diagnosis of insulin resistance. The auditor required the plan to re-review all CDC exclusions and submitted charts for the remaining correct exclusions from the measure. The auditor approved reporting.
2. For the two MRRV samples, there were two errors found _ one in each sample. The auditor required the plan to do an analysis and demonstrate corrective actions.
The plan reported that one abstractor made the errors by incorrectly identifying the prior years CDC eye exams. The plan re-reviewed 100% of that abstractors hits and reversed 12 hits to misses. The plan had originally reported 100 admin hits and 200 hybrid hits for CDC eye exam. Of the 200 hybrid hits, 160 were measurement year eye exams, and 40 were negative retinopathy cases from the prior year. The auditor pulled another sample of 16, found no errors, and confirmed that the reported rate for the measure dropped from 73% to 70% as a result.
The auditor approved reporting.
3. The auditor found four errors in the first sample for AWC. He notified the plan and required them to do an analysis and demonstrate corrective actions. The plan submitted:
· the error investigation and results
· the policies and procedures that corrected the error
· a new sample of 16 that proved to have zero errors

The auditor approved reporting.

HEDIS 2013

1.16.2013 Asthma Medication Ratio (AMR) In Table AMR-D, ICD-9-CM Diagnosis code 506.4 is listed under both the emphysema and COPD rows. Is this correct?

No. Remove code 506.4 from the emphysema row. This will be corrected in the MY 2013 manual.

1.16.2013 Cholesterol Management for Patients With Cardiovascular Conditions (CMC) Under the event/diagnosis description on page 51 of the MY 2012 P4P manual, the sentence reads, Include AMI and CABG from inpatient claims only and use only. Use both facility and professional claims to identify AMI or CABG. Is the and use only a typo?

The and use only should not be in the sentence. The sentences should read Include AMI and CABG from inpatient claims only. Use both facility and professional claims to identify AMI or CABG. This will be corrected in the MY 2013 manual.

1.16.2013 Medical Record Review Validation Can an auditor substitute one member in the MRRV sample of 16 if that members chart cannot be found?

Yes, substitution for one member is acceptable only if the organization cannot collect the chart because a practitioner is unable or unwilling to release it. The auditor has two options: he can select an original sample of 17 members (16 plus 1 oversample), and use the replacement member if the organization was unable to obtain a chart for one of the first 16 members, or he can send a 17th member when he is notified that one of the original 16 charts was unobtainable.

The auditors work papers should note which members chart was refused. If possible, the auditor should get a copy of the providers refusal letter or e-mail.

HEDIS 2013