FAQ Directory

For measures with hybrid reporting methodology (HBD, BPD, EED), members who have not had a diagnosis of diabetes but receive diabetes medications for conditions other than diabetes (e.g., weight loss, heart failure) may be identified as valid data errors and replaced with a member from the oversample.
To meet criteria for a valid data error for these measures, the medical record must contain no evidence of diabetes and must contain evidence to substantiate the data error (how the member wound up in the measure, why it is incorrect). It is expected that the medical record will not contain evidence of diabetes, and will contain documentation that the patient is on the medication, and why. This documentation, in combination with no other documentation of diabetes in the medical record, meets criteria for a valid data error. Valid data errors are subject to review by the auditor.
Valid data errors work for the Hybrid Method only because medical record data are used to ensure that the member does not have diabetes. For the administrative method, these members remain in the measure as medical records are considered supplemental data that may not be used for identifying valid data errors, or when reporting the HBD, BPD and EED measures using the administrative method, or the KED, SMD, EDH and SPD measures, which are administrative-only measures.
We are working to refine the diabetes denominator related to off-label medication use. The next annual HEDIS public comment period is planned for February–March 2023, but organizations may submit comments on any measure, at any time, through PCS (you do not need to wait until February).

*This FAQ applies to the following measures: Hemoglobin A1c Control for Patients With Diabetes (HBD), Blood Pressure Control for Patients With Diabetes (BPD), Eye Exam for Patients With Diabetes (EED), Kidney Health Evaluation for Patients With Diabetes (KED), Statin Therapy for Patients With Diabetes (SPD), Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD), and Emergency Department Visits for Hypoglycemia in Older Adults With Diabetes (EDH)

HEDIS 2022

No. The use of another entity’s evidence-based content within the organization’s case management system is not considered delegation if the organization maintains control over how the content is used and can customize it as needed. The evidence used to support the content must be cited.

HP 2023

Yes. The following changes apply to the 2022 MA Deeming Module:

• MA 19, Element A:
  • Clarified that the organization’s delegation agreements for MA standards must include a statement requiring delegates to adhere to MA regulations.
• SNP 2, Element A:
  • Revised factor 3 to reference both initial and annual health risk assessments (HRAs).
  • Clarified in the explanation that the organization must conduct an initial and annual HRA using a comprehensive HRA tool and ensure that results are addressed in the member’s individualized care plan, as required under 422.101(f)(1)(ii).
• SNP 2, Element C:
  • Added factor 2: “The organization annually, and within the first 12 months of enrollment, conducts face-to-face encounters between the member and their care team.” The face-for-face encounter must be either in person or through visual, real-time, interactive telehealth.
  • Adjusted the scoring to reflect the new factor.
  • Revised the explanation to include “Factor 2: Face-to-face encounter” subhead and text. The encounter must be between the member and representative from any of the following:
    • The ICT.
    • The organization’s case management and coordination staff.
    • A health care provider contracted with the health plan.
• SNP 3, Element A:
  • Revised factor 5 to read: “Including the ICT, as outlined in SNP 2, Element C, to oversee the MOC’s evaluation and monitoring process.”
  • Revised the scope of review to clarify that the organization includes the ICT in the monitoring and evaluation process.
  • Replaced the “Factor 5: Appropriate personnel” subhead with “Factor 5: The ICT” and revised the explanation to read:
    • The organizational chart documents the organization’s reporting structure and staff responsible for administering the MOC program, including the ICT, as specified in SNP 2, Element C, factor 1. According to the defined MOC, the organization must use an ICT to manage member care. The ICT includes:
      • Practitioners with demonstrated expertise and training,
      • Training in a defined role appropriate to their licensure in treating individuals similar to the targeted population of the organization, as applicable.

HP 2022

No. The use of another entity’s evidence-based content within the organization’s case management system is not considered delegation if the organization maintains control over how the content is used and can customize it as needed. The evidence used to support the content must be cited.

MBHO 2023

No. The use of another entity’s evidence-based content within the organization’s case management system is not considered delegation if the organization maintains control over how the content is used and can customize it as needed. The evidence used to support the content must be cited.

CM 2020

No. The use of another entity’s software to collect credentialing information is not considered delegation unless the other entity also reviews the information on the organization's behalf. NCQA standards allow organizations to use software to collect credentialing information from approved sources, as long as organization staff document that the information was reviewed and verified.

HP 2023

PCMH 2017

PCSP 2019

Evaluators may ask practices to provide an explanation, or context and reasoning, for the data submitted. If a reported performance rate seems too low (or too high), the evaluator may ask the practice to enter an explanation of the performance in the Notes section of QPASS.  

Practices are expected to provide a clear and succinct response as to why their performance rate is low, or unusually high. Because practices are expected to have fully implemented PMCH workflows and processes, the Review Oversight Committee (ROC) members would like to understand the reasoning behind the reported performance rates.  

PCMH 2017

No. The measure requires evidence of an advance care plan during the measurement year, dated during the measurement year. If the advance care plan is scanned into the EMR and dated in the measurement year, it meets criteria. If the plan is found in the EMR or member record from a prior year, it does not meet criteria unless there is dated evidence that it was reviewed or discussed during the measurement year.

HEDIS 2022

No. Medication reconciliations performed during a post-op/surgery follow-up visit alone do not meet criteria even if the visit was performed by the provider who admitted the member or who performed the surgery, or if the procedure is typically performed inpatient. The intent is that medical record documentation must support awareness of the hospitalization (denominator event) at the time of the medication reconciliation, even if the provider admitted the member or saw the member during the hospitalization, or if the procedure is typically performed inpatient. 

HEDIS 2022

Yes. Although LOINC codes were removed from the INR Test Value Set, organizations should use laboratory claims and data for this value set, in addition to medical claims. This value set should be listed in General Guideline 28 with other value sets that do not contain LOINC codes.

Exchange 2023