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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6.15.2013 Documentation to meet structural standards if delegated to an NCQA Accredited or Certified organization According to the Automatic Credit for Delegating to an Accredited HP appendix, there are some structural requirements that do not receive automatic credit when delegating to an NCQA Accredited or Certified Health Plan. What documentation is required if the organization accepts the delegates structural requirement as its own?

For all standards/elements that have been identified as structural requirements, the organization must provide its own materials, processes and other data sources as evidence that it meets each structural component of the standard. Organizations may adopt other organizations' procedures as its own. If an organization adopts existing procedures from another organization, it must provide evidence of formal adoption by its governing body or other group or individuals with appropriate authority.

6.15.2013 Number of sets of minutes for Interim Surveys How many sets of minutes are required for Interim Surveys? Many organizations seeking Interim Accreditation will barely be able to have one or two meetings before survey, especially new health plans, like CO-OPs.

For Interim Surveys, NCQA reviews up to three minutes. If there are fewer than 3 meetings, the organization presents the minutes from the meetings it has held.

6.15.2013 Medical record review requirement for Exchanges in Florida and Pennsylvania Is a medical record review required for Exchanges coming through Interim Survey in Florida or Pennsylvania?

No. Because Exchanges come under federal statutes, and medical record review is not required at this time under the federal statutes, medical record review is not included in Interim Surveys in Florida and Pennsylvania.

6.15.2013 Look-back period for Exchange products coming through Renewal Survey What is the look-back period for Exchange products coming through a Renewal Survey (i.e. concurrently with an existing NCQA Accredited product)?

The look-back period is prior to the survey date for the Exchange product line.

6.15.2013 Documentation for Interim Surveys for interpreter services What is the required documentation for interpreter or bilingual services since there may be no membership? What is required as evidence?

The organization must provide a documented process describing how it plans to meet the requirements when it does have a membership with a need for such services.

5.16.2013 General Guidelines Does an ICD-9 code of "411" mean that only code "411" is to be used, or do we also include all successor codes: 411.0, 411.1, 411.81, 411.89?

Unless otherwise noted, codes are stated in the minimum specificity required. For example, if a three-digit code is listed, it is valid as a three-, four- or five-digit code. If a table lists ICD-9-CM Diagnosis code 401, the codes 401.0, 401.1 and 401.9 are acceptable for P4P reporting. When required, a code will be specified with an x, which represents a valid digit that must be used for reporting. For example, ICD-9-CM diagnosis code 640.x1 indicates that any valid fourth digit can be used if the fifth digit is 1.

5.15.2013 When ER files are included in the universe of files for review When are ER denial files included in the universe of files for file review during an Accreditation or Certification Survey?

Generally, ER denials are not included in the universe of files for initial UM decisions unless a denial is appealed. In that case, the ER appeal is included in the universe of files for appeals.

UM-CR 2013

5.15.2013 National Student Clearinghouse as a source for education and training Does NCQA accept the National Student Clearinghouse (NSC) as a source for education and training?

The NSC is not recognized by NCQA as a source for education and training. However, the NSC would be considered an agent of the medical or professional school if the school has a contract with the Clearinghouse to provide verification services. The organization must provide documentation that the specific school has a contract with the Clearinghouse.

UM-CR 2013

5.15.2013 Monitoring Medicare Opt-Out Physicians May MA organizations use NPDB-HIPDB as a source of information for Medicare opt-out physicians?

No. The NPDB-HIPDB may not be used as a source for verifying a practitioner's status in relation to the Medicare Opt-Out Program. MA organizations can check with their states' Medicare Opt-Out list.

MA 2013

5.15.2013 Pay-for-performance Program If our organization displays information about our pay-for-performance program but does not display physician performance information for this program, how does NCQA score PQ 3A, 3B, 3C, 3D and 4B?

PQ 3A factors 3-5 and PQ 3B are scored NA if the organization does not display physician performance information for the pay-for-performance program.

PQ 3 C and D are scored against the pay-for-performance requirements if the organization has one complaint process for all programs. If the organizations complaint process is program-specific, PQ 3C and D are scored NA for the pay-for-performance program. NCQA scores PQ 4B factor 1 and the customer portion of factor 4 NA for the pay-for-performance program.

Because there is no NA scoring option in PQ 3B, 3C and 4B, these requirements are scored yes for pay-for-performance programs described above until the NA scoring option is added during the 7/29 release of the ISS tool.

PHQ 2013

4.16.2013 Proportion of Days Covered (PDC) The specifications require a pharmacy benefit, but POs do not have access to pharmacy benefit information. How do we verify that a member has a pharmacy benefit, and the start and end dates for that benefit?

If a PO receives pharmacy claims for a member, it can assume that the member has a pharmacy benefit, and that the pharmacy benefit dates align with the medical benefit dates.

4.16.2013 Proportion of Days Covered (PDC) The measure specification does not have an anchor date. How do we attribute members without an anchor date?

The Index Prescription Date (IPD) can be used as the anchor date.