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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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10.15.2019 Organization Responsibility for Chart Review HEDIS 2020 clarified that chart pursuit is recommended but is determined by the organization. Does this mean that chart pursuit is up to the organization?

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.

HEDIS 2020

10.15.2019 “Unknown” SES Category The SES stratification guidance in HEDIS 2020 Volume 2 indicates that the “Unknown” category may be used for only Puerto Rico plans or if the auditor approves a small number of unassigned members. Is there a specific number of Unknown members a plan is allowed to report?

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.”

HEDIS 2020

10.15.2019 Medication Dispensed Date If pharmacy data are classified as supplemental and the medication dispensed date is not documented, may the “shipped date” be used as the “dispensed date”?

No. The “shipped date” may not be used as “dispensed date” date when reporting the pharmacy measures.

HEDIS 2020

10.15.2019 Pharmacy Data and Medication Samples If pharmacy data are classified as supplemental, may the date when a provider gives free medication samples to a member be considered the “dispensed date”?

Yes. The date when the provider gives the medical sample to the member is considered the “dispensed date” when reporting pharmacy measures.
 

HEDIS 2020

10.15.2019 Codes Found in Medical Records For General Guideline 31: Supplemental Data, does removal of the hybrid data elements requirement mean that codes found in the medical record may be used as proof of service even if there is no additional documentation of the service provided?

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.

HEDIS 2020

10.15.2019 Reporting of the Initial Population by Data Source A bullet in the Summary of Changes in the DRR, AIS and PRS measures states: Removed the collection of the “Initial Population” and “Denominator” data elements by SSoR in the Data Elements for Reporting tables. This contradicts the Data Elements tables of all three measures, which has the initial population reported by data source. Is the SOC correct?

No. Replace the language with: Removed the collection of the “Denominator” data element by SSoR in the Data Elements for Reporting tables. The Data Elements tables are correct for the DRR, AIS and PRS measures and the initial population is reported by data source.

HEDIS 2020

10.15.2019 General Guideline 18: Deceased Members Is General Guideline 18: Deceased Members an optional exclusion? Must a deceased member be removed from all HEDIS measures?

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.

HEDIS 2020

10.15.2019 Supplemental Data and Rules for Allowable Adjustments In some cases, supplemental data are not allowed for regular HEDIS reporting, but may supplemental data sources be used when following the Rules for Allowable Adjustments?

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:

  1. For denominator calculation. The current restriction in regular HEDIS reporting is based on auditability, not on the data’s effect on the measure’s clinical intent. In Allowable Adjustments, files may be used if they meet all measure requirements.
  2. For Numerator calculation. The current restriction in regular HEDIS reporting is based on assessing paid claims vs. denied claims. In Allowable Adjustments, files may be used if they meet all requirements of the measure, even if the organization cannot determine payment status.

HEDIS 2020

10.15.2019 Survey requirements for PHM 6, Elements A and B What does NCQA review in PHM 6, Elements A and B, for First Surveys and Renewal Surveys?

For Element A

  • For First Surveys, NCQA reviews the organization’s plan for annual comprehensive analysis of its PHM strategy impact or the organization’s most recent annual comprehensive analysis of its PHM strategy impact.
  • For Renewal Surveys, NCQA reviews the organization’s most recent annual comprehensive analysis of its PHM strategy impact.

For Element B

  • Element B is NA for First Surveys.
  • For Renewal Surveys, NCQA reviews the organization’s most recent annual comprehensive analysis of its PHM strategy impact.

NCQA will clarify these requirements in the November Policy Update. 

HP 2020

10.15.2019 2020 HEDIS measures for Accreditation Ratings Is there a resource that outlines the 2020 HPR methodology, including the list of HEDIS and CAHPS measures required for Accreditation?

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

HP 2020

10.15.2019 Telemedicine Practitioners and Organizations Telemedicine providers are included in the scope of organizational providers in CR 7, Element A, as well as within the scope of credentialing in CR 1–CR 6. If telemedicine practitioners are credentialed under CR 1–CR 6, are they (or the company arranging care they provide) subject to assessment of organizational providers under CR 7?

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.
 

HP 2020

10.15.2019 CR 7, Elements D and E: Assessing Medical and Behavioral Healthcare Providers Does NCQA require a separate tracking mechanism or report for each provider?

No. The organization must provide documentation of a tracking mechanism—or mechanisms (e.g., checklist or spreadsheet)—that encompass the required provider types

HP 2019