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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3.15.2012 Practitioner participation in the QI program QI 2, Element A, factor 3 requires practitioner participation in the QI program. Is it enough for an organization to only include a medical director in planning, design, implementation and review of the QI program?

No. More than one practitioner must be involved in QI program activities. Participating practitioners must represent a broad spectrum of specialties, as appropriate.

3.15.2012 Assessment against access standards If the organization-level assessment shows that established goals and thresholds were not met for access to appointments, must there be an additional assessment at the practitioner level?

Yes. If performance issues are identified through organization-wide analysis, the organization must perform an analysis at the practitioner level to identify the cause. Practitioner-level assessment may include the total population or a statistically valid sample.

3.15.2012 Cultural preference If an organization only assesses language and gender and matches member and practitioner based on linguistic and gender data, is this acceptable for QI 4, Element A, factor 1?

No. Organizations must assess members cultural, racial, ethnic and linguistic needs then take actions based on its findings. Leaving out one or more of the required assessment areas would not meet the intent of the element.

3.15.2012 Demonstrating improvement Must an organization achieve significant improvement on identified opportunities to meet this element?

No. Data collection methodology must be sound enough to produce valid and reliable results but achievement of significant improvement is not required for QI 10 Element A.

3.15.2012 Analysis of complaint and appeal data May organizations analyze complaint data by the five specified complaint categories and analyze appeal data by the type of procedures appealed?

No. While the organization may have different complaints and appeal category for business purposes, it must analyze and report both complaint and appeal data by the five specified categories for NCQA purposes. Even if the organization has no complaints or appeals in one or more reporting categories, it must still demonstrate its analysis and report the number of complaints and appeals for all five categories.

3.15.2012 QI Work Plan Must the QI work plan address all the items listed under Work plan in the explanation to receive credit for QI 1, Element A, factor 9?

Yes. To receive credit for factor 9, the work plan must address all ten items listed Work Plan in the explanation.

2.16.2012 MY 2011 P4P Crosswalk to HEDIS 2012 NDC List When looking for the NDC list for P4P tables CWP-C and URI-D, to which table in HEDIS should we crosswalk?

For MY 2011 P4P tables CWP-C and URI-D, crosswalk to the HEDIS 2012 NDC list for table CWP-C.

*Note: The MY 2011 P4P crosswalk to HEDIS 2012 NDC List posted on December 8, 2011, has been corrected.

2.16.2012 Meaningful Use of Heath IT (MUHIT) Page 115 of the manual was updated to state, POs must have functional EHRs in place 90 days before the end of the measurement year (i.e., the POs EHRs must be functional by October 1, 2011). Define functionality. Our organization has been using an EHR system for a number of years (before October 1, 2011), but we have a backlog in becoming fully functional, as defined in each measure. Do we receive credit for all of the measures?

No. For the MUHIT domain, functionality means a fully operational and implemented system that has been in use since October 1, 2011. An organization that has an EHR in place, but is not using it as defined in the measure intent statement, does not receive any points for that measure.

2.16.2012 Meaningful Use of Heath IT (MUHIT) For MY 2011, what is the definition of Primary Care Providers (PCPs)? Does this include Pediatricians?

For MY 2011, POs should use their own designation of PCPs. This is in alignment with how P4P had defined PCPs for the IT-Enabled Systemness Domain.

2.16.2012 Meaningful Use of Heath IT (MUHIT) Define intent as used in the Scoring and Required Submission sections of each measure. How do we know we meet a measures intent, with respect to Required Submission item 4 and Assigned Points item 5?

For the MUHIT domain, intent refers to the measures criteria, as specified in the Intent section. For Required Submission item 4, count the number of PCPs, or the number of patients assigned to PCPs who meet the criteria listed for each measure. Assign the number of points that correspond to the percentage of PCPs meeting the measures intent.

2.16.2012 Health Plan Clinical Measure File Layout Why are there three example tabs in the MY 2011 Health Plan Data Submission file layout?

In MY 2011, health plans may submit results for the Medicare product line and for the commercial product line. Because the Medicare product line is now reported by health plans, the Health Plan Clinical and Testing Measure file layouts have three tabs for the possible reporting scenarios (commercial HMO/POS and Medicare, commercial HMO/POS only, Medicare only).

Scenario 1: The health plan has both commercial HMO/POS and Medicare product lines

Clinical Measure File Layout: Plans that report for both the commercial HMO/POS and Medicare populations must have 66 clinical measure IDs per DMHC ID/Sub Unit, even if an individual PO has only commercial or Medicare enrollment.

Testing Measure File Layout: Plans that report for both the commercial HMO/POS and Medicare populations must have 31 clinical measure IDs per DMHC ID/Sub Unit, even if an individual PO has only commercial or Medicare enrollment.

Refer to Tab (5) Sample HP FileBoth Commercial and Medicare

Examples 1_3: The plan has commercial and Medicare product lines; Pos 11111-00, 22222-03, 22222-05 and 33333-05 also have commercial and Medicare members: the plan submits commercial and Medicare data for these Pos.

Example 4: The plan has commercial and Medicare product lines; PO 44444-01 has only Medicare members: the plan submits Medicare data for PO 44444-01 and populates commercial rows for PO 44444-01 with zero enrollment, zero denominator, zero numerator and rate NB.

Scenario 2: The health plan has commercial HMO/POS product line only

Refer to Tab (6) Sample HP FileCommercial Only: Plans that have the commercial product line only submit data for the commercial product. There are no rows for the Medicare product.

Clinical Measure File Layout: The plan reports 59 clinical measure IDs per DMHC ID/Sub Unit for the commercial product.

Testing Measure File Layout: The plan reports 10 testing measure IDs per DMHC ID/Sub Unit for the commercial product.

Scenario 3: The health plan has Medicare product line only

Refer to Tab (7) Sample HP FileMedicare Only: Plans that have the Medicare product line only submit data for the Medicare product. There are no rows for the commercial HMO/POS product.

Clinical Measure File Layout: The plan reports 7 clinical measure IDs per DMHC ID/Sub Unit for the Medicare product.

Testing Measure File Layout: The plan reports 21 clinical measure IDs per DMHC ID/Sub Unit for the Medicare product.

2.15.2012 Notification of expedited external review for Medicare in UM 7, Element D How is factor 4 scored for Medicare members in UM 7, Element D?

Factor 4 is scored "NA" if a plan issues a Notice of Denial of Medical Coverage (NDMC) for non-inpatient medical services denials for Medicare members.