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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11.16.2012 General Guidelines If a member was included in the denominator because of inaccurate claims data, may we remove the member from the measure? How do we do this?

Members who are in the denominator because of inaccurate claims data may meet the criteria for a valid data error. Valid data errors are identified only for hybrid measures during medical record review. If a member is in the denominator because of a claim with a code specified for the measure, the medical record must contain evidence that the member does not meet measure criteria; a silent chart is not evidence that the member does not have the condition being measured. If the valid data error criteria are met, the member should be removed from the sample and replaced with a member from the oversample.

Finding valid data errors is not intended to be a method of correcting improper billing practices, and they cannot be identified through supplemental data. Additional information and examples of valid data errors can be found in the Substituting Medical Records in the Guidelines for Calculations and Sampling (page 51).

This applies to the following Programs and Years:
HEDIS 2013

11.16.2012 Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia The CMC event/diagnosis criteria were revised in the Volume 2 Technical Update to include both facility and professional claims when identifying an AMI or CABG event. Should both facility and professional claims be included when identifying AMI or CABG for the SMC measure?

Yes. Organizations should include AMI and CABG from inpatient claims only, but may use both facility and professional claims to identify these events for HEDIS 2013 reporting.

This applies to the following Programs and Years:
HEDIS 2013

11.16.2012 Care for Older Adults May a yes/no checklist be used for the advance care planning indicator?

If "yes" is checked, it may be counted as evidence that the member executed an advance care plan. If "no" is checked, evidence of an advance care planning discussion must be documented. A checklist does not count as evidence of a discussion.

This applies to the following Programs and Years:
HEDIS 2013

11.16.2012 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents For the Counseling for Nutrition and Counseling for Physical Activity indicators, do educational materials sent to members via mail or e-mail count toward the numerators?

No. The intent of the measure is to identify instances where a member received counseling for nutrition and physical activity; therefore, educational materials sent via mail or e-mail do not indicate that counseling occurred. The intent of including "member received educational materials" in the measure specifications is to allow for occasions where a provider gave educational materials to a patient during a face-to-face visit.

This applies to the following Programs and Years:
HEDIS 2013

11.16.2012 Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia In the Volume 2 Technical Update, the Continuous Enrollment criteria were revised to read "the measurement year and the year prior to the measurement year." Should the Allowable Gap criteria also include the year prior to the measurement year?

Yes. Members should have no more than one gap in enrollment of up to 45 days during each year of continuous enrollment.

This applies to the following Programs and Years:
HEDIS 2013

11.16.2012 Use of High-Risk Medications in the Elderly When calculating the Average Daily Dose for medications in Table DAE-C, should organizations use rounding rules before comparing the dose to the specified threshold? How should organizations calculate average daily dose for elixirs and concentrates?

Organizations should not round when calculating average daily dose. To calculate average daily dose for elixirs and concentrates multiply the volume dispensed by dose and divide by days supply.

This applies to the following Programs and Years:
HEDIS 2013

11.16.2012 Race/Ethnicity Diversity of Membership The note below table RDM-C-1/2/3 indicates that the "Unknown" category includes only members for whom the organization has not sought direct or indirect race/ethnicity information. If an organization sought this information but could not obtain it from the member, is this included in the "Unknown" category?

Yes. The Unknown category should be used in cases when the organization did not obtain race/ethnicity information using the direct or indirect data collection method or did not receive a "Decline" response. If the plan attempted to collect the information and the member gave a "Decline" response, the member is counted in the Direct Data Collection percentages (because the plan asked about the members race/ethnicity and received a response). The plan receives credit for attempting to collect the information, even though the member refused to provide it.

This applies to the following Programs and Years:
HEDIS 2013

11.16.2012 Medication Reconciliation Post-Discharge If a member's discharge is followed by a readmission or direct transfer to a nursing home or long term care facility, is the discharge included in the measure's denominator?

If there is evidence that the member remained in the nursing home or long-term care facility through December 1 of the measurement year, the discharge must be excluded from the denominator. If there is evidence that the member was discharged from the nursing home or long term care facility by December 1 of the measurement year, the discharge must be included in the denominator. Organizations may not assume that the member remained in a nursing home or long-term care facility through the end of the measurement year, based solely on the discharge status; there must be a method for identifying the members status for the remainder of the measurement year.

This applies to the following Programs and Years:
HEDIS 2013

11.15.2012 Tools for readiness evaluations Is there a non-Web based tool available for our organization to use for self-assessment?

An organization can use the PDF version of the standards to assess readiness to undergo a survey, but in order to undergo a survey it must purchase and use the Web-based Interactive Survey System (ISS) Tool. To purchase the PDF version of the standards or the Survey Tool, visit the NCQA Web site (www.ncqa.org) or contact Customer Service at 888-275-7585.

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Automatic credit for NQF endorsed surveys Does an organization that uses the NQF-endorsed CAHPS-CG survey receive automatic credit? If not, what is the organizations accountability for confirming factors in the measurement methodology?

An organization does not receive automatic credit for using CAHPS-CG for an NCQA Survey. For Element C, the organization must follow the aspects of the survey methodology outlined in the endorsed specification, and must specify how it will address all other aspects of methodology required by the element.

This applies to the following Programs and Years:

11.15.2012 Credit for Performance-Based Designation Programs as Quality measures Does use of Performance-Based Designation programs _ such as NCQA, BTE Recognition programs and Meaningful Use count as quality measures?

Yes, refer to Appendix 4: Performance-Based Designation Programs for the level of credit received for each program.

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Practitioners from the Indian Health Service (IHS) If our state Exchange asks our organization to consider using IHS practitioners, how should we handle NCQA licensure requirements given that these practitioners may not have a license to practice in our state?

It depends on the relationship between the organization and the practitioners, and what the state licensing agency allows. If the organization contracts with the IHS and directs its members to Indian Health Clinics, there is no need to credential individual practitioners for NCQA purposes, and consequently, no need to verify practitioner licenses. The clinics would fall under CR 8 in the 2013 HP Standards and Guidelines.

However, if the organization has an independent relationship with practitioners in a clinic and directs its members to these practitioners for care, the organization must credential the practitioners. The organization must verify practitioner licenses if the state licensing agency does not recognize the IHS license as a proxy for state license. Conversely, if the state licensing agency recognizes the IHS license as a proxy for the state license, there is no need to verify practitioner licenses. The organization must provide documentation showing state acceptance of the IHS license, during its survey.

This applies to the following Programs and Years: