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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8.15.2012 Evaluation Options: Basics For which Evaluation Options are organizations eligible if their accreditation has expired?

A plan whose accreditation status has expired or has been withdrawn for less than two years is eligible for the Renewal Evaluation Option with a 24-month look-back period.

A plan whose accreditation expired more than two years ago is eligible for accreditation through the Interim Evaluation Option or First Evaluation Options with a six-month look-back period.

8.15.2012 Evaluation Options: Basics Must NCQA-Accredited plans go through the Renewal Evaluation Option?

Yes. To maintain its accreditation, an NCQA-Accredited plan must go through the Renewal Evaluation Option.

7.16.2012 Medical Record Review Validation Does the audit timeline have a new MRR completion date?

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

7.16.2012 Medical Record Review Validation Why was a new statistical test chosen for MRRV?

The new test will reduce the number of errors allowed in the systematic sample collected using the Hybrid Method. Auditors will use the Squeglia Zero-based Sampling Plan, which includes more measures but has a smaller sample of 16 charts.

HEDIS 2013

7.16.2012 Medical Record Review Validation How can we prepare for the changes listed in the MRRV memo?

Communicate timeline changes and processes to staff; to your network of providers; to leadership at your plan; to medical record and copy vendors; and to your software vendor. Develop a plan and prepare with adequate resources for the HEDIS season. Add HEDIS performance guarantees with vendors to ensure clear understanding of goals and timelines.

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

7.16.2012 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 Medical Record Review Validation Does NCQA expect a decrease in rates with this new policy?

Although NCQA does not anticipate that rates will decrease, plans will need to start early and collect all data by May 15 to ensure that their rates are not affected.

HEDIS 2013

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 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 Why did the MRRV policy change?

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

7.16.2012 Medical Record Review Validation Has NCQA communicated the changes to the MRRV process?

Yes. We sent communication to plans, auditors, vendors, physician groups, purchaser groups and state and federal agencies.

HEDIS 2013