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.
By “regular business hours,” NCQA means 8 am-5 pm, Monday-Friday. The practice determines its hours of operation. Offering appointments between 7am and 4pm meets the criterion. The intent is that practices provide appointments outside typical business hours, to accommodate patients’ access needs. A practice could also shift staff hours—some staff work from 7 am-4 pm weekdays; some staff work from 8 am-5 pm weekdays—to enhance access.
PCMH 2017
For HEDIS 2020 reporting, enrollment segments are determined based on enrollment data provided by the health plan. If a plan provides the member's enrollment in different products/product lines as different enrollment segments, or even enrollment in the same product/product lines as different enrollment segments, the start date of the last enrollment segment must be used.
HEDIS 2020
Using General Guideline 33, the 12/30/2019 test is used as the most recent test while the 1/3/2020 result is within 7 days of the test, it is after the date threshold in the measure and may not be used. The result is counted as missing and the member is compliant for the HbA1c Testing and HbA1c Poor Control indicators. The member is not compliant for the HbA1c Control <7 for Selected Populations and HbA1c Control <8 indicators.
The 9/30/2019 test cannot be used as it is not the most recent.
Note: Ensuring results in the year after the measurement year are not counted is not tested in HEDIS 2020 Measure Certification.
HEDIS 2020
The intent of GG 37 is to prevent double-counting when an organization uses both pharmacy data (NDC codes) and clinical data (RxNorm codes) for reporting, because the same dispensing event can have both an NDC code in the pharmacy data and an RxNorm code in the clinical data. Because the two codes identify the same dispensing event (not two dispensing events), count an NDC code and an RxNorm code on the same date of service as one dispensing event and do not sum the days supply.
HEDIS 2020
Use the “Route” information from the tables to apply the “Definitions” for calculating an “inhaler dispensing event” and an “injection or intravenous dispensing event.” For routes listed as “subcutaneous” or “intravenous,” use the “injection or intravenous dispensing event” definition.
Note: In the MLD, the “Route” column lists “subcutaneous” and “intravenous” as “injection.”
HEDIS 2020
NDC codes can be used to identify different medications at different points in time. The NDC code 50090096201 identified digoxin .125 mg until July 2017 and was reassigned to digoxin .25 mg in 2019. The code is included in both lists because of the time frame NCQA used for removing obsolete NDC codes (the look-back period for the measure plus two additional years).
Because it is likely that the code on a claim during the calendar year indicates digoxin .25 mg and because this issue may impose confusion when programming the measure, organizations may elect to remove the NDC code from the Digoxin .125 mg Medications List for HEDIS 2020 reporting. Measure Certification will only test this code as part of the Digoxin .25 mg Medications List.
HEDIS 2020
For mapping purposes, the organization must demonstrate that the medication being mapped is the same as a medication listed in the Medication List Directory (MLD). For example, the route for “benralizumab” is listed as “subcutaneous” in the Asthma Controller Medications table (p. 153 HEDIS 2020 Volume 2).
The MLD contains two generic products for benralizumab: “1 ML benralizumab 30 MG/ML Prefilled Syringe” and “benralizumab 30 MG/ML Prefilled Syringe,” where the Route is listed as “injection.” Therefore, it would be appropriate to map a code with the generic name “benralizumab” and strength “30 MG/ML and dose form or route of either “syringe” or “prefilled syringe” or “injection.”
Another example is fluticasone, which is listed as “inhalation” in the Asthma Controller Medications table. The MLD (Generic Product Name) identifies appropriate dose/forms as “metered dose inhaler” or “dry powder inhaler,” and lists the route as “inhalation.” Therefore, it would be appropriate to map codes for fluticasone if the strength/dose matches one in the MLD and if the dose form or route is “inhaler” or “metered dose inhaler” or “powder inhaler” or “inhalation.” It would not be appropriate to map codes for fluticasone with dose form or route of “nasal spray.”
HEDIS 2020
For measures where different drugs are included in the same medication list with no variable to differentiate between “same or different,” the organization develops its own method. It is appropriate for the organization to assume that an NDC code and an RxNorm code on the same date of service are for the “same drug” and count as one dispensing event; however, this will not be tested as part of measure certification.
HEDIS 2020
The Mental Health Taxonomy Value Set was added in HEDIS 2020 to be used by organizations that report HEDIS using clinical (non-transactional) data. An organization that has taxonomy codes in transactional data may continue to map taxonomy codes not included in the VSD to taxonomy codes in the VSD, with auditor approval.
HEDIS 2020
