ER denial files will not be included in the UM denial file review (UM 4 – 7); however, appeals of ER denials will be included in the Appeals file review (UM 9).
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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10.15.2012 Excluding ER denial files from the UM denial file review With the elimination of the ER file review (UM 12, Elements B and C), will ER denial files be included in the UM denial file review for UM 4 - 7?
10.15.2012 Basics What is the value of obtaining Case Management Accreditation?
10.11.2012 Submission of NCQA WHP Performance Measures When must organizations submit NCQA WHP Performance Measures in order to obtain Accredited With Performance Reporting (AWPR) status?
Organizations coming through the WHP accreditation process for the first time and that wants to earn AWPR status must submit audited measures with the ISS Survey Tool submission. Organizations with current AWPR status must submit measures on April 15 to maintain the AWPR status. Organizations that do not submit performance measures with their Survey Tool can apply for an upgrade to AWPR status at the next annual submission date (the April 15 following receipt of accreditation status).
WHP 2013
9.16.2012 Cervical Cancer Screening The USPSTF released new recommendations for cervical cancer screening in March 2012. It recommends cytology (Pap test) screening every three years for women 21_65 years of age or, for women 30_65 years of age who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every five years. In light of the new recommendations, will NCQA update the CCS measure to account for the lengthened screening for women 30_65 years?
In response to USPSTF recommendations, NCQA has scheduled the CCS measure for reevaluation in 2012. The appropriate staff and panels will review updates and other relevant guidelines and will evaluate potential changes to the measure. Proposed changes, if any, will be posted for Public Comment in February 2013 and, pending final approval by the NCQA Committee on Performance Measurement, will be included in HEDIS 2014.
HEDIS 2013
9.16.2012 General Guidelines Can an organization continue to collect medical records for members in the hybrid sample after the May 15 medical record review deadline and record them in supplemental database for use in the current reporting year?
9.16.2012 Medication Reconciliation Post-Discharge The Medication Therapy Management (MTM) program is required for CMS Parts C and D data validation audits. May we use data from the MTM program to satisfy the "medication reconciliation" requirements in the MRP measure?
Data from the MTM program may be used only if the organization can distinguish a member's discharge medications from the member's current medications. The reconciliation must have occurred on or within 30 days of discharge by a prescribing practitioner, clinical pharmacist or registered nurse to meet the intent of the measure.
HEDIS 2013
9.15.2012 Basics What are the benefits for completing the Exchange Add-on Survey?
1. Allows you to market your Exchange product as NCQA Accredited to Exchanges and potential members.
2. Allows you to meets Exchange accreditation requirements, for those Exchanges that require Exchange _specific Accreditation.
3. Its a streamlined and efficient process, where plans need to attest that they will operate their Exchange the same as their accredited product. Unless there are many differences, NCQA will not review further documentation.
9.15.2012 "In-print" format Is including a "print" option in an online document enough to meet NCQA's "in print" requirement?
9.15.2012 Contact Information Who can I contact if I would like to learn if the Exchange Add-on Survey is the correct path for my plan?
9.15.2012 Basics What is highest accreditation status I can receive through the Exchanges Add-on Survey?
9.15.2012 Timing How long does it take to receive an accreditation status?
Once you submit your application, NCQA will determine if your organization is eligible for automatic accreditation. If you apply before February 1, 2013 and NCQA determines your organization is eligible for automatic accreditation then NCQA will award the accreditation status in the first quarter of 2013. If you apply after February 1, 2013 and NCQA determines your organization is not eligible for automatic accreditation then NCQA will award the accreditation status about two months after you apply.
If upon review of your application, NCQA determines that your organization is eligible for automatic accreditation, NCQA staff will contact you to schedule a date to start your Exchange Add-on survey and issue an ISS tool to you to complete and submit on the start date. If your organization achieves accreditation then the status will be awarded about three months after the start of the survey.
Note that NCQA posts accreditation status updates on its Web site once a month on the 15th of each month for statuses effective as of the end of the previous month.
9.15.2012 Timing What is the duration of the Exchanges Add-on Survey accreditation status?
The Exchanges Add-on Survey accreditation status is valid until your existing accredited products accreditation status expires.
For example:
You have Commercial HMO accreditation, which expires in January 2015.
You bring in your Exchange HMO for accreditation now, through the Exchanges Add-on Survey.
Your accreditation status for the Exchange product line is valid until your Commercial HMO expires in January 2015.