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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11.15.2012 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:

11.15.2012 Use of patient experience data collected from external organizations Is the use of patient experience data considered part of the program in the following circumstances: 1. The organization incorporates third-party performance information data with its own and then takes action on it (i.e., integrates the third-party data with its own to develop a composite that it reports or uses as the basis of action, such as payment or network or benefit design) 2. The organization provides a link for members on a third-party site so the member can review that information?

For scenario 1, the data must be considered as part of the program being reviewed for PHQ because the organization has incorporated the data with its own or tailored the data and then used the data as a basis for its own action (e.g., reporting, payment or network or benefit design). For scenario 2, if _ as part of its program _ the organization simply provides a link to an external source of performance information on physicians without altering that data and represents it as such, and the organization does not take any action based on the data (e.g., pay any incentive or use data for network or benefit design) then it is not considered part of the program.

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Eligibility for Case Management (CM) What organizations are eligible to pursue Case Management Accreditation?

NCQA considers entities that perform relevant functions to be eligible for NCQA CM Accreditation, including, but not limited to: CM organizations, population health management organizations, health plans (HP), managed behavioral healthcare organizations (MBHO), provider-based organizations– including medical groups, hospitals, integrated delivery systems, patient-centered medical homes (PCMH) and accountable care organizations (ACO), community care teams.

This applies to the following Programs and Years:
CM 2014

11.15.2012 Certification for information providers May an information provider earn certification for the pieces it provides (e.g., standards, methodology, underlying data), while its customer (i.e., health plan that publishes the information) pursues other pieces (e.g., member communication and complaints, physician communication)?

No. PHQ consists of the specified certification options: Physician Quality (PQ), Hospital Quality (HQ), or both. Contact phq@ncqa.org to discuss your situation so we can consider additional survey options to meet market needs.

This applies to the following Programs and Years:
PHQ 2013

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 Automatic credit for Case Management (CM) If an organization is NCQA DM Accredited, what documentation does it need submit to receive automatic credit for CM 8: Rights and Responsibilities and CM 9: Privacy, Security and Confidentiality Procedures?

To receive automatic credit for CM 8: Rights and Responsibilities and CM 9: Privacy, Security and Confidentiality Procedures, NCQA DM Accredited organizations should attach a copy of your accreditation certificate in the Interactive Survey System (ISS) to the relevant standards and elements.

This applies to the following Programs and Years:

11.15.2012 Timing for Program Input In the Element B explanation under the head Feedback Timeframe requires the organization to seek feedback annually and Element C _ Program Impact requires the organization annually asses the program. Does the organization have to carry out these activities annually if its measurement cycle is every two years?

No. An organization that measures its physicians every two years can meet the requirement by seeking feedback and assessing the program every two years.

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Methodology for evaluation of cost measures What constitutes an acceptable methodological approach to evaluation of cost?

NCQA does not prescribe the cost measures an organization selects, though it requires an organization to specify all aspects of its methodology (Element C). In addition, the organization must risk-adjust its measures (Element C, factor 8) and must meet the minimum statistical requirements for measurement error and measure reliability (PQ1 Element D, factor 2).

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 HEDIS measures If we use HEDIS measures, will NCQA still look at code?

No. NCQA does not evaluate an organizations code; it reviews the organizations measure specifications and compares them to the original source specification (if applicable). Note that to be considered from a standardized source, the measure must be the version specified for the level measured; e.g. HEDIS physician level measures, not plan level measures.

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Patient experience measures Do the results of Patient Experience of Care surveys, using questions derived from CAHPS-CG, have a role in the evaluation of physician quality?

Yes. Patient experience measures are considered measures of quality. The organization may use items or composites from the CAHPS-CG survey. Measure specifications for the CAHPS-CG survey can be found on the AHRQ website (https://cahps.ahrq.gov/clinician_group/).

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 WHP Performance Measure Reporting What is the process for reporting performance measure results for Accredited With Performance Reporting (AWPR) status?

Organizations are responsible for reporting NCQA WHP performance measure results exactly as specified if they are seeking AWPR status. Organizations must submit performance measure results to NCQA and attain a score of 50% or higher on WHP 12, Element A.

In order to retain AWPR status, organizations must annually submit performance measure results. Organizations that are NCQA Accredited in Wellness and Health Promotion and want to upgrade to AWPR status must submit measure results by the next annual reporting date (April 15) in any year during the accreditation cycle.

Organizations typically complete the WHP Performance Measures Reporting Tool, an Excel workbook. They send the workbook to an NCQA-Certified Auditor to have their measure results audited before submission. The auditor completes the audit worksheet in the Reporting Tool and locks the workbook, the returns the workbook to the organization, which subsequently submits the tool to NCQA.

This applies to the following Programs and Years:
WHP 2013

11.15.2012 Attribution Do the NQF or HEDIS provider-level measurement specifications define attribution? For example, to whom to attribute performance: the diagnosing MD, prescribing MD, provider with most encounters and so on? If not, does this not result in variation?

Neither NQF nor HEDIS provider-level measures specifications require a specific attribution method, although HEDIS measures provide options for an organization to consider. While this might result in variation from one organization to another, there is currently no single industry standard method for attribution.

This applies to the following Programs and Years:
PHQ 2013