Yes. Although NCQA recommends that organizations using the Hybrid Method pursue charts for all noncompliant members in the systematic sample, ultimately, the decision is the organization’s.
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.
Except for plans in Puerto Rico, which report all members in the “Unknown” category, it is expected that the member count in this category will be at or below 1%. If more than 1% of eligible members are assigned to the “Unknown” category, the plan must work with the auditor to identify why members are being categorized as “Unknown.”
No. Codes alone (without additional documentation of the service provided) do not meet criteria for proof of service. If a provider performs a service, it is expected that additional documentation exists in the medical record or in the primary source document. Auditors must validate, through primary source verification, all elements required by the administrative measure specification.
The exclusion in General Guideline 18 is optional. Members who die during the measurement year may be excluded from all measures, except the measures in the Health Plan Descriptive domain or the Risk Adjusted Utilization subdomain. However, if a member dies during the measurement year, the organization is not required to remove the member from all measures.
For example, if an organization identifies a deceased member during medical record review for the ABA measure, the member may be removed from the measure as a valid data error and replaced with a member from the oversample, but the organization is not required to remove the member from all other applicable HEDIS measures.
Additionally, there is no requirement to assess numerator compliance for deceased members and exclude the member only if they are not numerator compliant. NCQA does not prescribe how organizations identify deceased members using claim/encounter and enrollment data. Organizations must develop their own methods to identify these members.
Yes. Supplemental data may be used for the denominator and the numerator when following the Rules for Allowable Adjustments. In general, the data are usable when the codes are in the value sets and the clinical intent of the measure is not changed, but there are restrictions for use of supplemental data in regular HEDIS reporting:
For Element A
For Element B
NCQA will clarify these requirements in the November Policy Update.
The structure of Accreditation scoring is changing, beginning with Health Plan Accreditation 2020 and the 2020 HEDIS reporting year, when Accreditation and Health Plan Ratings will align. All organizations undergoing annual reevaluation in 2020 are included in the change to Ratings.
The links below provide information on the Health Plan Ratings, including the measures required for 2020 Accreditation.
Visit https://www.ncqa.org/wp-content/uploads/2019/07/20190731_2020_Health_Plan_Ratings_Methodology.pdf for information on the HPA Methodology document.
Visit https://www.ncqa.org/programs/health-plans/health-plan-accreditation-hpa/current-customers/hpa2020/scoring-updates/ for information on scoring updates.
Visit https://www.ncqa.org/wp-content/uploads/2019/05/2020-HP-Accreditation_HEDIS-CAHPS-Measures.pdf for the link to the HEDIS and CAHPS measures list for 2020
It depends. If telemedicine practitioners are credentialed under CR 1–CR 6, organizations are not required to also assess the telemedicine organization under CR 7, but if telemedicine practitioners are not credentialed under CR 1–CR 6, the telemedicine organization must be assessed under CR 7.