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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1.15.2021 Transitions of Care (TRC) Volume 2 states that for MY 2021 reporting, the organization may reduce the sample size using the prior year’s audited, product line-specific rate. Which rate should organizations use for sample size reduction?

Organizations may reduce the sample size for the TRC measure based only on the prior year’s audited, product line-specific rate for the lowest rate among all reported TRC indicators.

HEDIS 2022

1.15.2021 General Guideline 15 When a member has dual enrollment in Medicaid/Medicare how long must the member be enrolled in Medicare (PFFS or primary Medicare enrollment in another organization) to be removed from the Medicaid product line?

There is no minimum enrollment requirement. Per General Guideline 15, members must meet the measure’s continuous enrollment requirements and be considered dually enrolled based on continuous enrollment criteria or the service date.
Organizations must follow General Guideline 15 with regard to assessing coverage and should review enough data to meet the measure specification requirement.

HEDIS 2022

1.15.2021 General Guideline 15 What is the time frame for assessing dual enrollment?

As stated in the General Guideline 15, the time frame is assessed by measure. For measures with continuous enrollment, dual enrollment is determined as of the end of the continuous enrollment period, or the last enrollment segment, if there is a gap at the end of the continuous enrollment period.
For measures without a continuous enrollment requirement, members must have dual enrollment on the date of service or the date of discharge.

HEDIS 2022

1.15.2021 General Guideline 15 What type of Medicare enrollment counts when assessing members with dual Medicaid and Medicare enrollment?

General Guideline 15 includes language about Medicare contracts required to report HEDIS. These are meant to indicate Medicare Part C or Medicare Parts A and B. Having only Medicare Part D does not qualify as coverage for dual enrollment.

HEDIS 2022

1.15.2021 Follow-Up After Hospitalization for Mental Illness (FUH) What value sets can be used to identify community mental health center visits (the fifth bullet in the Numerator)?

The fifth bullet in the Numerator is missing value set references. Replace the bullet text with:
A community mental health center visit (Visit Setting Unspecified Value Set; BH Outpatient Value Set; Observation Value Set; Transitional Care Management Services Value Set) with (Community Mental Health Center POS Value Set).

**This FAQ applies to QRS MY 2020.

Exchange 2021

1.05.2021 Utilization Measures & Enrollment by Product Line (ENP) Are members with unknown or third gender excluded from member months tables that only designate binary gender?

Yes. Members with unknown or non-binary gender are excluded from only the utilization measures that require a specific gender (male or female) and the ENP measure because this measure requires a gender to be assigned in the reporting tables. NCQA continues to track industry standards for non-binary gender.

*Originally posted on 11/16/2020, this FAQ was updated on 1/5/2021.  

HEDIS 2022

12.15.2020 Use of Opioids at High Dosage (HDO) The MLD Update Memo stated, “Add Acetaminophen Hydrocodone 7.5 MGPML Medications List to the Medication Lists column and 7.5 mg per mL to the Strength column.” However, this medication list is not included in the MLD (the MLD contains an Acetaminophen Hydrocodone 7.5 mg Medications List).

The MLD content is correct; the item in the MLD Update memo contains an error. Organizations should “Add Acetaminophen Hydrocodone 7.5 mg Medications List to the Medication Lists column and 7.5 mg to the Strength column.”

HEDIS 2022

12.15.2020 Transitions of Care (TRC) May supplemental data be used for all four indicators in the Transitions of Care (TRC) measure?

Yes. Supplemental data may be used for all four indicators, including indicators that do not allow administrative reporting (Notification of Inpatient Admission and Receipt of Discharge Information).

Because there are no administrative codes to map to for the Notification of Inpatient Admission and Receipt of Discharge Information indicators, supplemental data must include all elements required by the measure's hybrid specifications for these indicators and once validated, the plan must determine how to get the results integrated for reporting. Plans should work with their vendors and this process should be reviewed and approved by the auditor.

HEDIS 2022

12.15.2020 Controlling High Blood Pressure (CBP) & Comprehensive Diabetes Care (CDC) - BP control (<140/90 mm Hg) Is the use of average blood pressure readings allowed?

Yes, but only average readings that include separate values for systolic and diastolic blood pressure may be used for reporting.

HEDIS 2022

12.15.2020 Transitions of Care (TRC) Where in IDSS should supplemental data be reported when it is used for the Notification of Inpatient Admission and Receipt of Discharge Information indicators?

Supplemental data for Notification of Inpatient Admission and Receipt of Discharge Information indicators must be reported in the “Numerator events by supplemental data” data element in IDSS.

HEDIS 2022

12.15.2020 Risk Adjusted Utilization Guideline 1 & Emergency Department Utilization (EDU) In the EDU measure, step 1 for the Calculation of Observed Events says to exclude ED visits that result in an inpatient stay or an observation stay. Should denied claims be used when looking for both an inpatient stay and an observation stay in this case?

Yes. When confirming that an ED visit does not result in an inpatient stay or an observation stay, all inpatient and observation stays must be considered, regardless of payment status (paid, suspended, pending, denied). Measure Certification will test this scenario to ensure all inpatient and observation stays are considered, regardless of payment status. For example, if an ED visit is paid but an inpatient stay is denied, the ED visit resulted in an inpatient stay and is not included in the Emergency Department Utilization measure when identifying observed ED visits.

HEDIS 2022

12.15.2020 Corrective Action Plan Question: What is the corrective action process for organizations that do not meet a must-pass element?

A Corrective Action Plan (CAP) is required when an organization does not meet the minimum threshold for one or more must-pass elements. The CAP must be submitted to NCQA within 30 days after receipt of the final Accreditation status and must meet NCQA approval. The organization undergoes a CAP Survey that focuses on the failed must-pass elements (not at the factor level), i.e., all element factors, will be reviewed in addition to the factor(s) that failed the must-pass requirement.
NCQA schedules the CAP Survey for submission 6 months following the organization’s last full survey; the file review is 4 weeks later. The organization’s Accreditation status is noted “Under Corrective Action” status modifier noted on the report card during the corrective action period.
The fees for the CAP Survey can be found in the Pricing Exhibit on My NCQA. The look-back period is from the date of implementation of the corrective action up to the CAP Survey submission date and may be between 3 and 6 months before the CAP Survey submission.
After successful completion of the CAP Survey, the status modifier is removed from the organization’s status on the report card. The expiration date of the Accreditation status remains the same as the date specified in the decision that precipitated the CAP Survey. If a CAP Survey is unsuccessful, the Review Oversight Committee (ROC) may:

  • Extend the CAP status modifier, or
  • Reduce the organization’s status from Accredited to Provisional or from Provisional to Denied, or
  • Issue a Denied Accreditation status.

UM-CR-PN 2019