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 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.

This applies to the following Programs and Years:

1.16.2013 Medical Record Review Validation Can the plan choose to rotate a measure that failed MRR validation?

The intent of measure rotation is to reduce chart review, not be a means to select the best rate possible. However, NCQA does not specifically prohibit this approach. Please note, if the reason for failing can be seen as possibly affecting other measures in the group, the auditor may elect to review those other measures.

This applies to the following Programs and Years:
HEDIS 2013

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.

This applies to the following Programs and Years:
HEDIS 2013

1.16.2013 Cholesterol Management for Patients With Cardiovascular Conditions (CMC) Under the event/diagnosis description on page 51 of the MY 2012 P4P manual, the sentence reads, Include AMI and CABG from inpatient claims only and use only. Use both facility and professional claims to identify AMI or CABG. Is the and use only a typo?

The and use only should not be in the sentence. The sentences should read Include AMI and CABG from inpatient claims only. Use both facility and professional claims to identify AMI or CABG. This will be corrected in the MY 2013 manual.

This applies to the following Programs and Years:

1.16.2013 Medical Record Review Validation Can auditors provide plans with the measures selected for over-read earlier than May 1? What if the plan finishes MRR earlier?

The current timeline says that the auditor selects the measures for review on May 1 and not before; however, if the auditor reviews the health plans internal timelines, and finds that the plan expects to finish MRR early, it is acceptable that the auditor send the measure list when all chart review is complete and he has received a final count of numerator hits for each hybrid measure. For example, if the plan finishes all chart chases on April 29 and provides the numerator count lists, the auditor can select the measures for validation and start the process early.

Note: If the auditor allows for an earlier MRRV timeline, the plan may have to adjust other deadlines affected by this change.

This applies to the following Programs and Years:
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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

12.16.2012 Annual Monitoring for Patients on Persistent Medications (MPM) The Measure Updates section for MPM states that LOINC code 62425-4 was added to Table MPM-B, but in Table MPM-B LOINC code 6425-4 was added. Is the code listed in Table MPM-B missing a digit?

Yes. The LOINC code added to Table MPM-B should be 62425-4. This will be corrected in the MY 2013 manual.

This applies to the following Programs and Years: