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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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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 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 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 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

7.15.2012 Determinations on non-creditable coverage requests If a member does not have creditable coverage, are decisions on pre-existing conditions considered medical necessity determinations?

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.

7.15.2012 Extending the time frame for initial assessment How many failed attempts to locate or communicate with a member must be made before an organization can exclude the member from a complex case management program?

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.

5.16.2012 Proportion of Days Covered by Medications (PDC) For the PDC measure, if a 30 day prescription is filled before the start of the measurement year but spills over into the current measurement year, how is it counted? For example, if a member fills a 30-day prescription on 12/15/10, does it count for MY 2011, for the 15 days that the prescription lasts into MY 2011?

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.

5.15.2012 Remove notice of new appeal reviewer from the denial letter For UM 7, Elements D and G, factor 2, must the explanation of the appeal process include notice that a new, nonsubordinate reviewer will be appointed?

No. The denial notice does not need to include notification that a new, nonsubordinate reviewer will be appointed; however, the organization must include this requirement in its appeal policies and procedures to meet UM 8, Elements B and C, factor 5, and include it in applicable appeal files to meet UM 9, Element C.

5.15.2012 Appeal notices in a culturally and linguistically appropriate manner What does NCQA look for in an appeal notification that meets the "culturally and linguistically appropriate manner" requirement?

"Culturally and linguistically" appropriate refers to the organization providing notices of the appeal process to non-English-speaking members, in languages appropriate to members.

5.15.2012 Verification of certification for an unrecognized board Does NCQA only accept ABMS and AOA sponsored boards as verification sources? What does NCQA require for verification of boards from non-ABMS or non-AOA boards if the practitioner claims to be board certified?

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.

5.15.2012 Verification of certification for an unrecognized board Does NCQA only accept ABMS and AOA sponsored boards as verification sources? What does NCQA require for verification of boards from non-ABMS or non-AOA boards if the practitioner claims to be board certified?

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.

5.15.2012 Clinical quality measures across programs May organizations use the same clinical quality measure for each program brought forward for accreditation?

Yes. Organizations may use the same clinical quality measure for each program if the measure is relevant to each program's population. Each program's population must be measured separately.