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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3.16.2013 General Guidelines I am a self-reporting PO who plans to submit results for Medicare members. Please clarify which health plans members I should include.

A self-reporting PO submits clinical results based on all Medicare members belonging to a participating health plan:

  • Anthem Blue Cross.
  • Blue Shield.
  • Health Net.
  • SCAN.
  • UnitedHealthcare.

This applies to the following Programs and Years:

3.16.2013 Evidence-Based Cervical Screening (ECS) For Measurement Year 2012, would a member who had a Pap test and an HPV test on different dates of service in 2009 or 2008 fall in Rate 1 (Appropriately Screened) or in Rate 2 (Not Screened)?

The member would fall in Rate 2 (Not Screened) because the Pap test and the HPV test occurred on different dates of service.

This applies to the following Programs and Years:

3.16.2013 Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) In HEDIS 2013, Table ART-C includes code J3262, but P4P does not. Please confirm that it should be included.

Table ART-C should include J3262. This will be corrected in the next release of the P4P manual.

This applies to the following Programs and Years:

3.16.2013 Encounter Rate by Service Type (ENRST) Table ENR-F in the Encounter Rate by Service Type measure has instructions to download codes from the CMS Web site, but the referenced file is no longer on the site. The instructions refer specifically to a spreadsheet titled Addendum AA-ASC Covered Surgical Procedures (ASC_AddAA.csv) for October 2012 from the site http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html

When I click the link, it brings up a download file named "asc-october2012-aa-bb-dd1-dd2-ee.zip," which has an excel spreadsheet and 5 txt files, ASC AA, ASC BB (and so on). Are these correct? Which should we use?

3.15.2013 Eligibility for accreditation prior to establishing relationships Is an organization eligible for accreditation if it does not perform the functions specified within the standards and guidelines directly and has not entered into an effective service agreement with another entity to perform the function?

No. To be eligible for accreditation, an organization must perform the functions specified in the standards and guidelines (e.g., QI, UM, CR, RR and MEM, if applicable), either directly or through a service agreement.

This applies to the following Programs and Years:

3.15.2013 Web chat as a means of meeting MEM 4, Element A Does the availability of a Web chat meet the requirements for an attempt or contact to meet MEM 4, Element A?

Yes. As long as the member can receive the information or complete the listed activities in the element in one attempt or contact, a Web chat will meet the requirements. The organization would need to provide documentation explaining how the system works and evidence of completion of the specified actions.

This applies to the following Programs and Years:

3.06.2013 Proportion of Days Covered (PDC) The specifications state, "if the member has two distinct measurement periods in one measurement year, exclude the member due to a gap in enrollment." Please clarify.

If a member has two separate 90+ day enrollment periods during the measurement year, each with a pharmacy benefit, exclude the member due to a gap in enrollment.

If a member has two separate enrollment periods, one for fewer than 90 days, include the member in the measure but count only the 90+ day enrollment period. Use the date of disenrollment from the 90+ day enrollment period as the end of the measurement period.

If a member has two separate enrollment periods, one with no pharmacy benefit, include the member in the measure but count only the enrollment with the pharmacy benefit. Use the date of disenrollment from the enrollment period with the pharmacy benefit as the end of the measurement period.

This applies to the following Programs and Years:

2.16.2013 General Guidelines If an organization finds an undated lab result in a progress note, can the progress note date be used as the lab result date?

No. An undated lab result may not be used for HEDIS reporting. To be eligible for use, the date the test was performed (e.g., the date the sample was drawn) or the result date (e.g., the date the lab calculated the result) must be documented.

This applies to the following Programs and Years:
HEDIS 2013

2.16.2013 Meaningful Use of Health IT Domain Documentation is required for 5% of PCPs/EPs reported as using certified software, with documentation for a minimum of 2 and a maximum of 5 PCPs/EPs. Does this mean we need to provide documentation for 5 different PCPs for each measure?

No. Documentation is required for 5% of PCPs/EPs reported as using certified software, but the same PCP/EP may be used for every measure. For example, the following scenarios are acceptable documentation:

  • The PO has a global report for all PCPs/EPs for all 20 MUHIT measures. This report would be the only documentation required for Measures 1-20; the PO would simply need to attach this report to the survey and associate the same document with each measure.
  • The PO has dashboard reports for individual PCPs/EPs, for all 20 MUHIT measures. If the PO has 60 PCPs on certified software, 5% of those 60, or 3 PCPs are required to have documentation. The PO may attach the dashboard reports, which detail all 20 MUHIT measures including threshold requirements, for 3 PCPs, and associate those three documents with each measure. There is no need to pick 3 separate PCPs for each measure.
  • If the PO has access to the CMS attestation reports, these may be used as documentation for Measures 1-15. If the PO reports 60 PCPs/EPs on certified software, the PO may attach the CMS attestations for 3 PCPs (5% of the 60), and associate the three CMS attestations with each of Measures 1-15. Separate documentation may be required for the CMS menu items, if they are not specified in the CMS attestation.

This applies to the following Programs and Years:

2.16.2013 Meaningful Use of Health IT Domain I was sent an email with log-in instructions for accessing the MUHIT survey, but I am not the contact at my organization who will be filling out the survey. Can you assign the survey to someone else in my PO?

We have assigned one contact per PO to the MUHIT survey, and that person may add as many users as necessary to the survey. Instructions for adding users to the survey are as follows:

  • Go to the Manage User tab
  • Select Add User
  • Select Create a User
  • Enter email address of the person from your PO you want to add
  • Create a password. If the contact you are adding already has access to the P4P PO reports, they will use the same password.
  • Assign one of the following two roles: Administrators: Manages users, fills out the survey, submits the survey; Assessors: Fills out the survey.

This applies to the following Programs and Years:

2.16.2013 Comprehensive Diabetes Care If no result is documented for an eye exam in the year prior to the measurement year, can the organization infer that the exam was negative for retinopathy?

No. Documentation of an eye exam that does not include a result does not count as a negative result and is not eligible for use in HEDIS reporting.

This applies to the following Programs and Years:
HEDIS 2013

2.16.2013 Adult BMI Assessment If the member's weight is documented in the medical record during the measurement year or year prior to the measurement year, may the organization calculate BMI at a later date?

Yes. The BMI may be calculated by the organization at a later date. It must be calculated and documented in the medical record during the measurement year or year prior to the measurement year to be eligible for use in HEDIS reporting.

This applies to the following Programs and Years:
HEDIS 2013