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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5.07.2019 QI 08 & AR QI 03 Would increasing survey response rate qualify as a measure for improving patient experience ( QI 11, AR QI 03)?

QI 08 & AR QI 03

No, increasing survey response rate is important in obtaining more representative patient feedback, but would not meet the intent of QI 08 or AR QI 03. The response rate is part of the platform for obtaining the feedback, while the measure for these criteria should be improving the feedback itself.

PCMH 2017

5.07.2019 QI 02 What are some examples that would qualify as resource stewardship?

QI 02

For care coordination, the intent of QI 02A is to evaluate the communication/coordination that occurs between providers or providers and patients, so it's generally looking at closing the loop on care coordination tasks/processes. Some examples for care coordination may include but are not limited to:
– Reduced % of patients seeing multiple providers (3 or more)
– Medication reconciliation after care transition (MU)
– Follow up with patients or providers to ensure ordered lab or imaging tests were completed
– Follow up with patients following receipt of abnormal test results
– Outreach to patients not recently seen that result in an appointment
– Follow-up phone calls to check on the patient after an ER visit (or hospitalization)
– # patient calls received after hours by the call center were reconciled in the patient record and addressed by the care team the next business day
– Following up on pediatric visits to after-hours care
– Number of referrals sent
– % of patients who had a positive TB screen who had a FU Chest x-ray
– % of patients who had a positive GC/Chlamydia who were treated with antibiotics
The intent of QI 02B is for practices to use measures to help them understand how efficiently they're providing care and judiciously using resources. Examples of measures affecting health care costs may include but are not limited to:
– Total cost per patient
– Medical cost per medical visit
– # of medications prescribed
– Use of high cost medications
– Use of imaging for low back pain
– Redundant imaging or lab tests
– Emergency department utilization
– Hospital readmission rates
– Use of generic versus brand name medication
– # of Specialist referrals
– # of patients who went to urgent care during open office hours
– # of referrals/ED visits for needs that could be addressed in the office
– Appropriate testing for children with pharyngitis
– Appropriate treatment for children with URI

PCMH 2017

5.07.2019 CM 09 Would sending the care plan to outside points of care via a secure, electronic fax meet the intent of CM 09?

CM 09

No, neither secure, electronic fax noR secure email would meet the intent of CM 09. For CM 09, the practice must demonstrate its capability to make their patient's care plans available securely to other care settings, such as hospitals, specialists, or other care facilities that could be managing patient care. This availability should be at the time the patient is seen, including after hours, and as such should not involve reaching out to the practice for the information to be sent. The way in which this care plan is shared may vary and NCQA is not prescriptive, but examples include sharing care plans via shared medical records, HIEs or other shared systems that enable staff from different care settings to view the patient's care plan for continuity and optimal care coordination while the patient receives care from multiple settings.

PCMH 2017

4.15.2019 Value-Based Payment Requirement for PHM 3, Element B 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.

HP 2019

4.15.2019 SES Guidance in Technical Update 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.

HEDIS 2019

4.15.2019 No Benefit Designation 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).

HEDIS 2019

3.15.2019 UM 8, Element A MAXIMUS 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.

HP 2018

3.15.2019 Citing a benefit provision 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

HP 2019

3.15.2019 LTSS 4, Element C: Analysis of Unplanned transitions 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.

CM 2019

3.15.2019 PHM 5, Element F: Aligning the examples with the factor explanation 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?

HP 2019

3.12.2019 PCMH Criteria and HIEs 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 

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) 

PCMH 2017

2.15.2019 Language in denial letters 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.

HP 2019