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 Can an auditor substitute one member in the MRRV sample of 16 if that members chart cannot be found?

Yes, substitution for one member is acceptable only if the organization cannot collect the chart because a practitioner is unable or unwilling to release it. The auditor has two options: he can select an original sample of 17 members (16 plus 1 oversample), and use the replacement member if the organization was unable to obtain a chart for one of the first 16 members, or he can send a 17th member when he is notified that one of the original 16 charts was unobtainable.

The auditors work papers should note which members chart was refused. If possible, the auditor should get a copy of the providers refusal letter or e-mail.

This applies to the following Programs and Years:
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.

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:

1.16.2013 Medical Record Review Validation If during MRR validation, a plan fails two samples, and informs the auditor they corrected the problem, what follow-up items are required to validate that the corrections were appropriate?

The auditor may use one or more methods to validate the chart error corrections. Follow-up actions should include:
· reviewing the error investigation and results
· reviewing policies and procedures to correct the error
· reviewing the corrected sample to ensure the updated numerator counts are correct and performing final hybrid rate review
· re-sampling charts for a new validation

Examples:

1. For the exclusions or data errors in the diabetes measure records, the auditor identified a pattern: she found two cases where the chart reviewer said the members did not have diabetes, but the chart showed that both members had elevated blood sugars and above average HbA1c results. One member had a PCP diagnosis of metabolic syndrome that placed him in the measure. The other member had a diagnosis of insulin resistance. The auditor required the plan to re-review all CDC exclusions and submitted charts for the remaining correct exclusions from the measure. The auditor approved reporting.
2. For the two MRRV samples, there were two errors found _ one in each sample. The auditor required the plan to do an analysis and demonstrate corrective actions.
The plan reported that one abstractor made the errors by incorrectly identifying the prior years CDC eye exams. The plan re-reviewed 100% of that abstractors hits and reversed 12 hits to misses. The plan had originally reported 100 admin hits and 200 hybrid hits for CDC eye exam. Of the 200 hybrid hits, 160 were measurement year eye exams, and 40 were negative retinopathy cases from the prior year. The auditor pulled another sample of 16, found no errors, and confirmed that the reported rate for the measure dropped from 73% to 70% as a result.
The auditor approved reporting.
3. The auditor found four errors in the first sample for AWC. He notified the plan and required them to do an analysis and demonstrate corrective actions. The plan submitted:
· the error investigation and results
· the policies and procedures that corrected the error
· a new sample of 16 that proved to have zero errors

The auditor approved reporting.

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 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.

This applies to the following Programs and Years:
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.

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:

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:

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 Meaningful Use of Health IT Domain The Submitting the survey instructions in the Domain Structure of the Meaningful Use of Health IT domain specifications state that physician organizations must attach documentation for each measure, including documentation that thresholds for individual measures are being met. What kind of documentation is required, and how much?

POs must attach either a global report produced by the EHR detailing the entire POs performance on each measure, or dashboard reports detailing the performance of individual PCPs. Reports are required for 5% of all PCPs reported as using certified software. Documentation is required for a minimum of two and a maximum of five PCPs. For example, if 60 PCPs are reported as using certified software, documentation will be required for 5% of the PCPs (3 PCPs). If 120 PCPs are reported as using certified software, however, documentation is only required for 5 PCPs. Although 5% of 120 is 6, the maximum number of PCPs for whom NCQA requires documentation is 5.

This applies to the following Programs and Years: