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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1.16.2013 Medical Record Review Validation What happens if a plan doesnt report any measures in a group?

The auditor selects one measure from each measure group that applies to the health plan, and exclusions from the exclusions group. If the plan doesnt report any measures in a particular group, the auditor will use his discretion, based on past performance and current progress, to determine if an additional measure should be selected from a group already used.

HEDIS 2013

1.16.2013 Asthma Medication Ratio (AMR) In Table AMR-D, ICD-9-CM Diagnosis code 506.4 is listed under both the emphysema and COPD rows. Is this correct?

No. Remove code 506.4 from the emphysema row. This will be corrected in the MY 2013 manual.

1.16.2013 Medical Record Review Validation What records are included in Group F (Exclusions)?

MRRV Group F (Exclusions) includes all optional and required exclusions and valid data errors found during medical record review. It does not include records excluded through administrative data or that belong to employees or their dependents. Other hybrid medical record exclusions that should not be reviewed in Group F are exclusions for CBP and the HbA1C Less Than 7% indicator. Because of the large volume, auditors review exclusion rates for these indicators separately. See the instructions in Volume 5, page 65 for reviewing CBP and HbA1c<7%.

HEDIS 2013

1.16.2013 General Guidelines Is there a deadline for updating administrative rates with new sources of supplemental data?

Yes, the December Update included a modification to the audit timeline that requires all supplemental database activities be concluded by 5/1 in the reporting year. NCQA requires this deadline to allow sufficient time for audit review and possible corrections. The update should be made in the HEDIS Audit Timeline in Volume 5, on page 52 and in Volume 2, on page 17. This sentence should be added: "Auditor finalizes approval of Supplemental Databases, policies, procedures, and content (data)." by May 1.

HEDIS 2013

1.16.2013 Medical Record Review Validation If a plan has one failed medical record during MRR validation, and a second sample also fails, do the measure and all the measures in that group receive an NR?

If a plan fails the test – one error in each of two samples – and cannot correct the error and resubmit the correction to the auditor, the plan may not use the Hybrid Method for reporting that measure. The plan can report the administrative rate or report an NR for that measure. The auditor must determine whether the error affects all the other measures in the group and their reportability.

HEDIS 2013

1.16.2013 All-Cause Readmissions (PCR) The MY 2012 P4P manual states that the All Cause Readmission measure will be collected as part of Medicare and is a mandatory testing measure for P4P, but this measure is not listed on the IHA Web site in the MY 2012 measure set.

Although P4P will collect the All Cause Readmission measure from health plans as part of the regular P4P clinical submission process, technically, it is an Appropriate Resource Use measure. As such, it is listed as a testing measure in the Appropriate Resource Use section. Note: Only health plans will submit results for this measure.

1.16.2013 Medical Record Review Validation For measures that are heavily or entirely reliant on MRR data (e.g., COA, ABA, WCC, CDC BPs), if an organization attempts MRR validation and fails, or is able to retrieve a only small percentage of charts, can they report an administrative rate as low as 0% (assuming no other issues are identified)?

A low administrative rate, even 0%, can be reported, if the plan wants to submit such a rate and the auditor finds no bias or other problems in the administrative process.

HEDIS 2013

1.15.2013 Complex case management automated systems Must the entire clinical practice guideline be imbedded in the complex case management automated system?

No. The entire clinical practice guideline does not need to be imbedded in the automated system. However, the guideline components used to conduct assessment and management of patients must be imbedded in the system.

1.15.2013 Look-back period for review of delegates for Interim Surveys Do Interim Surveys include review of the program elements (QI 12C, UM 15C, CR 9D, RR 7D, MEM 9D)?

No. The scope of review should not include the elements and the look-back period should be NA for Interim Surveys for elements. We will clarify this in the March 2013 Policy Update.

12.17.2012 Interim Surveys including MED category Does the Interim Survey include the Medicaid (MED) elements?

Yes. The interim Survey includes the MED elements. The scope of review and look-back period will be revised to include the elements for Interim Surveys.

12.17.2012 Qualifications for practitioners who review medical necessity denials Does a practitioner have to be actively participating in an organization to review medical necessity denials?

No. Being an actively practicing practitioner is not a requirement for reviewing medical necessity denials, although NCQA does require practitioners to have the education, training and experience in clinical or medical practice and be currently licensed in order to meet the requirements to make UM decisions.

12.16.2012 Osteoporosis Management in Women Who Had a Fracture (OMW) When determining the eligible population for the OMW measure, access to inpatient claim/encounter data is necessary if a member had a fracture requiring an inpatient stays. Specifically, the inpatient claim/encounter data are required to calculate admission and discharge dates. Many self reporting POs are not at risk for inpatient stays and as such we do not have access to inpatient claim/encounter data. How are we suppose properly calculate the eligible population if we do not have inpatient claim/encounter data?

Physician organizations that do not have access to inpatient claim/encounter data may use professional claims indicating that a physician saw the member in the hospital, as a proxy. In this scenario, the physician organization uses the physicians first visit with the member as a proxy for the admission date and uses the last visit as a proxy for the discharge date. This alternative method may be used only by physician organizations that do not have access to inpatient claim/encounter data.