Where can I find the Medicaid Module Standards and Guidelines?
Submit your request for the 2018 Medicaid Module at My NCQA.
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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11.20.2018 How can I obtain the Medicaid Module Standards and Guidelines?
11.15.2018 What is Source of Payment (SOP) Typology?
All ECDS Measures
The Source of Payment Typology was developed to create a standard for classifying payer type. In measure specifications, it will enhance identification of specific payer identity in clinical data used for NCQA reporting.
Modeled loosely after the ICD typology for classifying medical conditions, the SOP Typology identifies broad payer categories (step 2) with related subcategories that are more specific to a product (steps 3 and 4). The first digit of each code represents the organization providing the funds for care; subsequent digits provide more-specific information about the mechanism used to provide funds. This format provides the flexibility to either use payer codes at a highly detailed level or to roll up codes to broader categories for comparative analysis across payers and locations.
SOP Typology can be used by anyone to code the payment data source. Use of the payer classification may require a crosswalk of previous code lists to the new hierarchical payer typology.
Example steps for plan classification using SOP Typology:
1. Plan needing typology classification: Harvard Pilgrim Health
2. Determine main category for first digit: 5 (Commercial)
3. Determine subcategory for second digit: 1 (Managed Care Private)
4. Determine subcategory breakdown for third digit: 2 (PPO)
5. Assign final SOP classification code: 511 (Commercial Managed Care-HMO)
11.15.2018 To calculate a member’s SES stratification, the instructions say to evaluate whether the member’s LIS values (item 35) are the same or different in the last 3 months of continuous enrollment (CE). How do you determine if a value is the same or different?
SES Guidelines
A value is different if it is either < or = 0 OR > 0. For the last 3 months of the CE period:
- Count the member as receiving an LIS payment if 2 of the last 3 months are >0, even if the values are different.
Example:
October LIS = 35
November LIS = 40
December LIS = -35
October LIS = 35
November LIS = 40
December LIS = -35
- Count the member as NOT receiving an LIS payment if 2 of the last 3 months are < or = 0, even if the values are different.
Example:
October LIS = 0
November LIS = -35
December LIS = 35
October LIS = 0
November LIS = -35
December LIS = 35
11.15.2018 To calculate a member’s SES stratification, the instructions say to use the Monthly Membership Detail Data Files (MMDDF) for the measurement year to assess the member’s LIS, DE payment status. We find that in some months, members have multiple rows of data in the MMDDF, which represent adjustments for previous months. What should we do in this situation; is there a better file to use for determining SES?
SES Guidelines
Because the SES assessment is new and requires files not normally used for NCQA’s measure calculations, we have explored options for reporting members with these scenarios, and we think there are options for these data.
NOTE: NCQA’s Certification program tests one record per member based on the MMDDF.
- Option 1: If you are using MMDDF and one month has multiple rows for a member with different values in one row or more, sum the values and use the result to compare to the other 3 months. Remember that what is important is whether the number is > 0 or it is < or = 0. See this example:
| Member | RunDate | LisPremiumSubsidy |
| 1 | 2018 10 12 | 0000.00 |
| 1 | 2018 10 12 | 0035.50 |
| 1 | 2018 11 08 | 0035.50 |
| 1 | 2018 11 08 | -0035.50 |
| 1 | 2018 11 08 | 0035.50 |
| 1 | 2018 12 08 | 0035.50 |
This member is counted as LIS eligible: the sum of October = 35.50, the sum of November = 35.5, and December = 35.50 (all months are >0).
- Option 2: If you have access to the LIS History (LISHIST) File, it can be used to determine LIS eligibility. CMS describes the file as the most complete picture of LIS eligibility over a period not to exceed 36 months. This data file includes LIS activity for past, present and future enrollees. A full copy of the Plan-Communications-User-Guide-v122-August-31-2018, which describes the file, can be found at https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/Plan-Communications-User-Guide-v122-August-31-2018.pdf. Below is an example of the corresponding records in the LISHIST file for the member shown above.
| Member | LowIncomePeriodStartDate | LowIncomePeriodEndDate | LipsPercentage | PremiumLisAmount | ContractYear |
| 1 | 2016 09 01 | 2016 12 31 | 100 | 36.00 | 2016 |
| 1 | 2017 01 01 | 2017 12 31 | 100 | 36.00 | 2017 |
| 1 | 2018 01 01 | 100 | 35.50 | 2018 |
This file clearly shows that the member was LIS eligible for the HEDIS 2019 measurement year (calendar year 2018). If you have access to this file, it may be the easiest, most accurate data to use.
NOTES:
- If the LowIncomePeriodEndDate is blank, the member is still eligible.
- Plans should use a copy of this file from January 2019 or later.
11.15.2018 Numerator 1 for immunization status: influenza lists prior anaphylaxis due to Haemophilus influenzae type b vaccine or its components any time during or before the measurement period as an option for meeting numerator criteria. Should this reference the influenza vaccine instead of the HIB vaccine?
Adult Immunization Status
Yes. This is an error listed in numerator 1. However, with the release of the October Update Memo, the HEDIS 2019 specifications are frozen.
Organizations must follow the specifications as written for HEDIS 2019 reporting. We will correct Numerator 1 in HEDIS 2020 to indicate that prior anaphylaxis must be due to the influenza vaccine.
11.15.2018 If a member is included in the ART measure due to a rule-out diagnosis, may the member be removed from the denominator based on medical record documentation indicating an incorrect diagnosis of rheumatoid arthritis?
Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
No. Members may not be removed from HEDIS measures due to billing errors. HEDIS does allow removal of “valid data errors” if they can be substantiated through medical record documentation; however, this applies only to hybrid measures. Because the ART measure is administrative only, the use of valid data errors is not permitted, nor may supplemental be used as a substitute for claims data (to correct billing errors) or to identify valid data errors.
11.15.2018 In the Guidelines for Measures Collected Using ECDS, General Guideline 5 states that members may not have more than one gap in enrollment of up to 45 days during the specified participation period. For most ECDS measures, the participation period is the measurement period (January 1–December 31), but for DRR and PRS the participation periods cover different time periods. How should allowable gaps be handled for these two measures?
Depression Remission or Response for Adolescents and Adults and Prenatal Immunization Status
For HEDIS 2019 reporting, the allowable gap in enrollment may occur any time during the specified participation periods for DRR and PRS. For example, for DRR, the allowable gap may occur any time during the participation period, including during April 1 of the year prior to the measurement period through December 31 of the year prior to the measurement period. With the release of the October Update Memo, the HEDIS 2019 specifications are frozen. Organizations must follow the specifications as written for HEDIS 2019 reporting. We will review this issue; any changes to the specifications will be made for HEDIS 2020.
11.15.2018 On page 458 under step 5 there are instructions for how the number of members in the eligible population data element is reported in IDSS. It states, “Enter these values in the reporting table (HPC-A-3).” However, in that table, the column titled “Members in the Eligible Population” is shaded gray, indicating that it is calculated by IDSS. Is the data element reported by the organization, or calculated by IDSS?
11.15.2018 When reporting Receipt of Discharge Information, if the PCP or ongoing care provider is the discharging provider, are the requirements the same to meet numerator criteria?
11.15.2018 When reporting Notification of Inpatient Admission and Receipt of Discharge Information indicators using an integrated EMR system, is a “received date” required in the EMR if the information was in the shared EMR on the day of admission/discharge or on the following day?
Transitions of Care
No. With a shared EMR, evidence that the information was filed/accessible by the PCP or ongoing care provider on the day of admission/discharge or the following day meets criteria for Notification of Inpatient Admission and Receipt of Discharge Information indicators. The organization is not required to find additional notation of a “received date” if it is evident that the information was in the shared EMR on the day of admission/discharge or the following day.
11.15.2018 When reporting the Patient Engagement After Inpatient Discharge indicator, if the member is unable to communicate with the provider, does an interaction between the member’s caregiver and the provider meet criteria?
11.15.2018 Do standard supplemental data files need to contain all data elements required by the hybrid specification, regardless of the method used by the plan to report the measure?
General Guidelines
Yes. As stated in General Guideline 30, both standard and nonstandard supplemental data files must contain all data elements required by the hybrid specification, regardless of the reporting method used (administrative or hybrid). However, for HEDIS 2019, NCQA makes an exception for only standard supplemental data files and for only the Adult BMI Assessment (ABA) and Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) measures.
Because the values (height, weight) used to calculate BMI are often stored in EMRs and not included in data extracts, NCQA does not want to penalize plans for not having these data elements in their data files. Auditors may approve standard supplemental data files that include only the date and the BMI value or percentile.
For the WCC nutrition and physical activity counseling indicators, a date of service and an applicable code from the VSD counts as compliant.
NCQA is evaluating the standard supplemental data requirement for all other hybrid measures for HEDIS 2020.