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.
Yes. For HEDIS 2013, NCQA will enforce a medical record review deadline of May 15 (the previous deadline was May 10). No charts will be accepted past this deadline, when auditors will begin to review records. Holding all plans to the same timeline ensures comparability among submissions.
HEDIS 2013
NCQA continually reviews the audit process to ensure that it meets all applicable reporting requirements and is the rigorous process expected by all stakeholders.
Responding to increasing pressure from incentive programs, and with CMS input, over the past year NCQA developed the audit policy described in the June 19 MRRV memo. This change will make a more exacting process that ensures enough time for auditing and reporting valid results.
HEDIS 2013
A member who cannot be located or communicated with after three or more attempts over a 2-week period may be excluded from complex case management, and the file may be excluded from review. The organization must document attempts to contact the member by various mechanisms (telephone, letter, e-mail or fax) and through authorized caregiver channels.
No. If a member does not have creditable coverage, or does not have enough coverage to offset the entire pre-existing condition exclusionary period, the denial is not considered a medical necessity determination and should not be included in the UM denial file review. However, the denial may be appealed, and should be included in the appeal file review.
No. A fill date from the previous measurement year is not included in current measurement year calculations. The text on page 180 of the MY 2011 P4P publication, under Index prescription date (IPD), should read [the IPD is the] first fill date during the measurement year. The member in your example is ineligible because the first fill date does not occur in the current measurement year.
No. With the exception of ABMS or AOA sponsored boards, NCQA requires organizations to determine and list specialty boards they accept within their credentialing policies and procedures. At a minimum, at least annually, organizations must obtain written confirmation from the specialty board that it performs primary-source verification of education and training. A specialty board that provides annual written confirmation that it conducts primary source verification of education and training can be used as an acceptable source for verification of education and training if the organization names the specialty board in its policies and procedures.
Organizations must include all programs or population segments to assess for WHP 9, Element A.
Data collection must be across all programs and include eligible participants. If an organization uses a sample, the sample must be randomized to give all eligible participants an equal chance of being included.
No. With the exception of ABMS or AOA sponsored boards, NCQA requires organizations to determine and list specialty boards they accept within their credentialing policies and procedures. At a minimum, at least annually, organizations must obtain written confirmation from the specialty board that it performs primary-source verification of education and training. A specialty board that provides annual written confirmation that it conducts primary source verification of education and training can be used as an acceptable source for verification of education and training if the organization names the specialty board in its policies and procedures.
The organization must verify board certification status for any practitioner claiming to be certified by an ABMS or AOA sponsored boards, or by a specialty board recognized by the organization.
