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.
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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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?
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?
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?
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?
2.15.2012 Behavioral healthcare practitioner involvement in program design Must the behavioral healthcare practitioner involved in program design be employed by the organization, or may the behavioral healthcare practitioner be a consultant?
2.15.2012 Personal care add-on benefits Are personal care services that are add_on benefits, such as cooking, grooming, transporting, cleaning and assistance with other ADL activities that are not part of medical benefit, subject to review under UM 4-UM 7?
No. Add-on personal care services do not fall within the scope of UM 4-UM 7, but they can be appealed under RR 2 or UM 8 and UM 9. Personal care services that are a part of the medical benefit fall within the scope of medical necessity review if an assessment must be done to determine the member is eligible for the services or if the services will be covered. In such cases, the services would be within the scope of UM 4-UM 7.
2.15.2012 Facility DEA What type of documentation should health plans include in credentialing files, if the DEA allows all practitioners in a community hospital/clinic to be covered under facility DEA?
2.15.2012 Verifying Sanction Information Every 30 Calendar Days Are organizations required to verify sanction information at recredentialing if the information is verified within 180 calendar days at initial credentialing, and every 30 calendar days thereafter?
The answer depends on whether the organization presents sanction information every 30 days to its Credentialing Committee. If so, there is no need to report it at the time of recredentialing. If not, the organization would need to verify and present adverse information to the Credentialing Committee at recredentialing.
2.14.2012 Notification of expedited external review for Medicare in UM 7, Element G How is factor 4 scored for Medicare members in UM 7, Element G?
1.17.2012 Use of Virtual Hold in call abandonment rates Our member phone system measures wait time. If the wait time hits a certain threshold, members can hang up, keep their place in the queue and receive an automatic call back when the next customer support person is available. The system is set to call back every five minutes, for three attempts. When members answer the call-back, they are connected to the customer support person. If a member does not answer after three attempts, is the call considered abandoned, based on the Call Abandonment criteria?
Yes. If the member does not answer the call-back, it is counted as abandoned. If the member answers the call-back and the reports show the results, the call is not counted as abandoned because the member was kept in the queue.
For timeliness (Element C, factor 1), because it is unlikely that the system would start the call-back process before 30 seconds, the call counts as answered outside the 30 seconds.