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 needed for Interim Surveys What documentation is expected for Interim Surveys in QI 7, Element B?

The organization must provide a documented process describing the system, and how it meets the requirements in the element.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

6.15.2013 Scoring for factors for Interim Surveys Factors 2, 4 and 5 require activities to have been in place for a period of time that is longer than is likely to be the case for organizations seeking Interim Accreditation, especially new health plans, like CO-OPs. How will these factors be scored?

Factors 2, 4 and 5 are scored NA for Interim Surveys.

This applies to the following Programs and Years:

6.15.2013 Delegation documentation for Interim Surveys For organizations coming through Interim Surveys, what documentation is expected to meet the delegation requirements?

For Interim evaluation options, if an organization has not finalized a delegation agreement with an intended delegate, NCQA will accept draft agreements and communications between organizations for delegation requirements. NCQA will review and score the draft agreement and communications defining when the agreement will be complete for Elements A (Written Delegation Agreement) and B (Provision of PHI) in the applicable categories (QI, UM, CR, RR). NCQA will also review documented processes and reports for Element D (Predelegation Evaluation). NCQA will score delegation Element C (Review/Approval of Program, Right to Approve and Terminate, Predelegation Agreement) as Not Applicable. NCQA reserves the right to review and score finalized delegation agreements.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:
UM-CR 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.

This applies to the following Programs and Years:
PHQ 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.

This applies to the following Programs and Years:
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.

This applies to the following Programs and Years:
MA 2013

4.16.2013 Adult BMI Assessment (ABA) The specifications state that ABA is the same measure as the CMS Stars measure Adult BMI assessment, which uses the HEDIS specification. The HEDIS specification defines continuous enrollment as the measurement year and the year prior, but the IHA specification defines continuous enrollment as only the measurement year. Which is the correct continuous enrollment?

The continuous enrollment should be the measurement year and the year prior to the measurement year. This will be corrected in the MY 2013 version of the P4P manual.

This applies to the following Programs and Years: