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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4.15.2019 If a value-based payment program is new, there may not be payments for all months of the look-back period. How can the program be documented to meet the requirement, and how should this be reflected in the workbook?

Value-Based Payment Requirement for PHM 3, Element B

The organization does not need to have value-based payments for every month of the look-back period. It reports:

As the numerator: The value-based payments made during the look-back period, and
As the denominator: All payments (including fee-for-service) made during the entire look-back period.

For example, the denominator is 12 months of all payments, but if there are 3 months of value-based payments in the look-back period, the numerator is the 3 months of value-based payments.

4.15.2019 The SES stratification guidance in the HEDIS 2019 Volume 2 Technical Update Memo 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?

SES Guidance in Technical Update

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 fewer than 10. Plans should determine why members are reported as “Unknown” and be able to explain the reason to their auditor.

This category should not be used for members who are disenrolled for the 2019 calendar year and consequently have no record in the December 2018 Monthly Membership Detail File. Use the October and November files for these members.

4.15.2019 How does an organization determine if the No Benefit designation is appropriate for reporting?

No Benefit Designation

General Guideline 25 in HEDIS Volume 2 explains that benefits are not assessed at the service level. Assessment of benefits must follow the measure specifications under the Benefit section of the Eligible Population criteria. Organizations may not assess benefits at a service level for an NB (No Benefit) audit designation.

For example:

· If the organization offers a pharmacy benefit but does not cover a specific medication class, the member has a pharmacy benefit and is included in the applicable measures requiring this benefit.

· If the organization offers a mental health benefit but does not cover inpatient visits, the member has a mental health benefit and is included in the applicable measures requiring this benefit, unless the measure benefit requires inpatient care, per the Eligible Population benefit requirements (e.g., Follow-up After Hospitalization for Mental Illness requires both inpatient and outpatient mental health coverage).

3.15.2019 What factors are scored “Met” for UM 8, Element A if an upheld denial was sent to MAXIMUS?

UM 8, Element A MAXIMUS

Factors 7-13 should be scored as “Met” for upheld denials sent to MAXIMUS.

3.15.2019 If a benefit provision is used as the basis for the denial, how must it be cited in the notification?

Citing a benefit provision

Referencing benefit documents such as the member handbook or Certificate of Coverage by title alone is not specific enough to meet the requirement. Because benefit documents are often large and complex, the organization must direct members to the specific location of the information, either by section title or page number.

The reference must still support the organization’s decision and relate to the reason for the request

3.15.2019 The explanation for LTSS 4, Element C, factor 1 states that analysis includes patterns of unplanned admissions, readmissions, emergency room visits and repeat visits, and admission to participating and nonparticipating facilities. Is the organization required to include all these areas to meet the intent of the factor?

LTSS 4, Element C: Analysis of Unplanned transitions

No. The organization is not required to include all these areas in its analysis, but at a minimum, must evaluate rates of unplanned admissions to facilities and emergency room visits to identify areas for improvement.

3.15.2019 Are the examples in PHM 5, Element F all-inclusive? Does using only the listed questions meet the requirement?

PHM 5, Element F: Aligning the examples with the factor explanation

No. As a general rule, examples should be used as a guide. Examples of questions for PHM 5, Element F that are not prescriptive, but address each requirement listed in the Explanation, include:

1. How satisfied are you with the information provided about the overall case management program?

2. How would you rate your experience with the case manager overall? With the program staff?

3. Did the case manager and other program staff treat you with courtesy and respect?

4. Was the information provided to you useful?

5. How well were you able to follow the recommendations provided to you by the case manager?

6. Were you able to achieve your health goals in your case management plan?

3.12.2019 Can utilization of a Health Information Exchange (HIE) meet PCMH criteria?

PCMH Criteria and HIEs

Participating in an HIE can help practices demonstrate PCMH criteria; however, connection alone does not demonstrate the evidence needed to meet the following criteria. Practices must demonstrate how they use the HIE to meet each criterion. Utilization of an HIE could help meet the following criteria:

PCMH Criteria		NYS PCMH Required Criteria
AC 12(2 Credits)	Continuity of Medical Record Information	✔
CM 09(1 Credit)	Care Plan Integration	✔
CC 15(Core)	Sharing Clinical information
CC 17(1 Credit)	Acute Care After-Hours Communication
CC 18(1 Credit)	Information Exchange During Hospitalization
CC 19(1 Credit)	Patient Discharge Summaries	✔
CC 21(Maximum 3 Credits)	External Electronic Exchange of Information	✔ (A is required)

2.15.2019 May an organization send a single denial letter to a member and a practitioner that contains the reason for the denial in both layman terms (for the member) and clinical terms (for the practitioner)?

Language in denial letters

Yes. The organization may send a single letter to the member and practitioner that includes the specific reason for the denial, in language that would be easily understood by the member. The letter may also include, in a separate section, additional clinical or technical language directed toward a practitioner.

When NCQA reviews the letter to ascertain if the reason for the denial would be easy for the member to understand, it considers both the written reason and the context of the language and whether the information can be understood in context.

2.15.2019 The “Total” data elements for Medicare in Table PCR-A must match the “Total Medicare” data elements in Table PCR-B. Are organizations required to report the totals in both tables?

Plan All-Cause Readmissions (PCR)

No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-A. Remove the “Total Medicare” row from Table PCR-B that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-A. The asterisked language may also be removed under these two tables.

2.15.2019 The “Total” data elements for Medicare in Table PCR-C must match the “Total Medicare” data elements in Table PCR-D. Are organizations required to report the totals in both tables?

Plan All-Cause Readmissions (PCR)

No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-C. Remove the “Total Medicare” row from Table PCR-D that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-C. The asterisked language may also be removed under these two tables.

2.15.2019 When pharmacy data are classified as supplemental data, the following data elements must be present: the generic name (or brand name), strength/dose, route and date when the medication was dispensed to the member. If all the required data elements are included except the dispense date, can a start date be used instead?

Supplemental Data

No. When pharmacy data are used as supplemental data, a dispense date is required; a start date may not be used as a proxy. There are no exceptions to the requirements for pharmacy data, as described in General Guideline 30.