Where can I find the Medicaid Module Standards and Guidelines?
Submit your request for the 2018 Medicaid Module at My NCQA.
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.
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)
A value is different if it is either < or = 0 OR > 0. For the last 3 months of the CE period:
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.
|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).
|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.
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.
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.
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.
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.
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.