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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8.15.2012 Evaluation Options: Basics Which Evaluation Option should plans with New Health Plan accreditation apply for next?

Plans with NHP accreditation must apply for the Renewal Evaluation Option with a 12-month look-back period.

8.15.2012 Evaluation Options: Basics How are the Interim Option and the First Evaluation Option different?

The Interim Evaluation Option has half of the number of elements as the First Evaluation Option, focuses on policies and procedures and is valid for 18 months.

The First Evaluation Option is valid for 36 months and focuses on policies and procedures, initial measurement and analysis of programs and file review.

Plans going through the Interim Evaluation Option can earn Interim status (HEDIS/CAHPS reporting is not required); plans going through the First Evaluation Option can earn either Provisional or Accredited status (if they are not scored on HEDIS/CAHPS).

Reporting is required during the third annual HEDIS reporting cycle for organizations going through the First Evaluation Option, which also gives plans the option to be scored on HEDIS/CAHPS results, allowing them to earn an accreditation status higher than Accredited.

8.15.2012 Evaluation Options: Standards and Guidelines Several elements in the First Evaluation Option require annual evaluation, even though the Evaluation Option has a six-month look-back period for all other elements. How do plans meet this annual requirement?

NCQA will expand the look-back period if it is necessary for plans to demonstrate that performance requirements are met and to produce an adequate sample for file reviews. For annual requirements, plans must complete the activity at least once during the prior year.

8.15.2012 Evaluation Options: HEDIS Reporting and Scoring When must plans report HEDIS/CAHPS measures if they are going through the First Evaluation Option?

Plans report HEDIS/CAHPS measures during the third annual HEDIS reporting cycle of their accreditation status. For example, if an organization receives a status in September 2014, it must submit audited HEDIS/CAHPS results in June 2017.

8.15.2012 UPDATED: Completely overturned denials excluded from file review Are overturned denials excluded from file review for only UM 9, Elements C and D, or from all elements in UM 9?

Files submitted on or after November 1, 2012, are not included in file review for any element in UM 9.

7.16.2012 Initiation and Engagement of Alcohol and Other Drug DependenceTreatment The Engagement of AOD Treatment indicator requires initiation of AOD treatment and two or more inpatient admissions, outpatient visits, intensive outpatient encounters or partial hospitalizations with any AOD diagnosis within 30 days AFTER the date of the Initiation encounter (inclusive). Does "inclusive" mean that the initiation visit is included when determining compliance for engagement? What does "after" mean?

"Inclusive" means that the initiation visit is included when determining compliance for the Engagement of AOD Treatment indicator; therefore, the initiation visit is day 1 in the 30-day count. "After" means that the two additional visits must occur after the date of the initiation encounter. For example, if a members initiation visit occurred on August 1, the engagement visits must occur on August 2 through August 30.

HEDIS 2013

7.16.2012 Medical Record Review Validation Have the criteria for determining a unique medical record process changed?

No. If the MRR processwhich includes training, tools, interrater reliability checks, rater-to-standard tests and any other quality control processis different by plan, product or product line, the auditor must conduct separate MRRV for each process by following the new validation steps.

HEDIS 2013

7.16.2012 Medical Record Review Validation Does NCQA expect a decrease in rates with this new policy?

Although NCQA does not anticipate that rates will decrease, plans will need to start early and collect all data by May 15 to ensure that their rates are not affected.

HEDIS 2013

7.16.2012 Initiation and Engagement of Alcohol and Other Drug DependenceTreatment In the Initiation of AOD Treatment indicator, the third paragraph states that if the Index Episode was an outpatient, intensive outpatient, partial hospitalization, detoxification or ED visit, the member must have an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization with an AOD diagnosis, within 14 days of the IESD (inclusive). What does "inclusive" mean?

"Inclusive" means the IESD is day 1 in the 14-day count for the Initiation of AOD Treatment indicator. The time frame for initiation is the IESD and the next 13 days, for a total of 14 days. For example, if a members IESD was an outpatient visit on August 1, the initiation visit must occur on or between August 1 through August 14.

HEDIS 2013

7.16.2012 Medical Record Review Validation Has NCQA communicated the changes to the MRRV process?

Yes. We sent communication to plans, auditors, vendors, physician groups, purchaser groups and state and federal agencies.

HEDIS 2013

7.16.2012 Medical Record Review Validation In HEDIS 2013, are there new requirements for MRRV?

For HEDIS 2013, NCQA will adopt a new audit process that uses like-measure groupings for measure validation, includes hybrid measure exclusions, applies a different statistical test to the process and clearly defines MRR milestones to ensure consistency across plans.

HEDIS 2013

7.16.2012 Medical Record Review Validation How can we prepare for the changes listed in the MRRV memo?

Communicate timeline changes and processes to staff; to your network of providers; to leadership at your plan; to medical record and copy vendors; and to your software vendor. Develop a plan and prepare with adequate resources for the HEDIS season. Add HEDIS performance guarantees with vendors to ensure clear understanding of goals and timelines.

HEDIS 2013