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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3.16.2012 Diabetes Care Blood Pressure Control (<140/90 mm Hg) In the November 2011 release of the MY 2011 P4P specifications, Blood Pressure Control (<140/90 mm Hg) for Diabetes replaced exclusions with the note, The blood pressure reading must be in conjunction with an outpatient visit code or a nonacute inpatient visit code from Table CDC-C. This new note requires physician organizations to map blood pressure pulled from a registry to claim data to identify the specific visit codes. This change is extremely burdensome! Why was it necessary?

P4P made this change to align with HEDIS, but did not consider the unintended impact it will have on POs, which must pull the information from EHRs. Because of the burden to POs, P4P will revert to the prior language for this measure, outlined below.

When identifying the most recent BP reading noted during the measurement year, do not include BP readings that meet the following criteria.

BPs taken during an acute inpatient stay (Table CDC-O)

BPs taken during an ED visit (Table CDC-P)

BPs taken during an outpatient visit where a diagnostic test or surgical procedure was performed (e.g., sigmoidoscopy, removal of a mole) or BPs obtained the same day as a major diagnostic or surgical procedure (e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy) (Table CDC-Q)

BP readings taken by the member.

3.16.2012 Continuous Enrollment and Allowable Gaps Over Multiple Years In the MY2011 P4P Manual, are the dates correct in the example for Continuous Enrollment and Allowable Gaps Over Multiple Years? They do not seem to match up to the description of gaps in enrollment.

There is an error in the manual. The first date in the example should be November 30, 2010. The full example should read as follows:

For example, in the MY 2011 Breast Cancer Screening measure (which requires 2 years of continuous enrollment), a member who disenrolls on November 30, 2010 (the year prior to the measurement year), and re-enrolls on February 1, 2011 (the measurement year), is considered continuously enrolled as long as there were no other gaps in enrollment during either year. The member has one gap of 31 days (December 1_31) in 2010 and one gap of 31 days (January 1_31) in 2011.

This error will be corrected in the September 2012 release of the MY 2012 manual.

3.16.2012 Breast Cancer Screening (BCS) On the Clinical Measure file layout the BCS measure is listed as Breast Cancer Screening: Ages 52-69 but the measure description indicates that it is for ages 50 _ 69. Is there an error in the Clinical Measure file layout?

The Clinical Measure file layout is correct. The age band is described as starting at age 52 to account for the two year look-back period for this measure.

3.16.2012 Annual Monitoring for Patients on Persistent Medications (MPM) In the November 2011 release of the MY 2011 P4P specifications, Table MPM-A: Drugs to Identify Members on ACE Inhibitors or ARBs does not match exactly with Table CDC-L in the 2012 HEDIS volume. Is this an error?

There is an error in the manual. In the Table MPM-A: Drugs to Identify Members on ACE Inhibitors or ARBs, in the row Antihypertensive combinations the drugs Aliskiren-valsartan, Amlodipine-hydrochlorothiazide-valsartan, Amlodipine-hydrochlorothiazide-olmesartan and Amlodipine-telmisartan should be included in the table.

This error will be corrected in the September 2012 release of the MY 2012 manual.

3.16.2012 Appropriate Testing for Children With Pharyngitis (CWP) In the November 2011 release of the MY 2011 P4P specifications, Table CWP-C: Antibiotic Medications does not match exactly with Table CWP-C in the 2012 HEDIS volume. Is this an error?

There is an error in the manual. In Table CWP-C: Antibiotic Medications,

in the row First generation cephalosporins, the drug Cephradine should not be in the table,

in the row Macrolides the drug Erythromycin estolate should not be in the table,

in the row Third generation cephalosporins, the drug Cefditoren should be included in the table.

These errors will be corrected in the September 2012 release of the MY 2012 manual.

3.16.2012 Asthma Medication Ratio (AMR) Based on the MY 2010 P4P Crosswalk to HEDIS 2011 NDC List document, P4P Table AMR-C crosswalks to the HEDIS table ASM-C for the NDC list, but long-acting inhaled beta-2 agonists are no longer included in Table AMR-C. Should they be used in the Asthma Medication Ratio measure for P4P?

No. Do not include long-acting inhaled beta-2 agonists when calculating the Asthma Medication Ratio measure.

3.16.2012 Diabetes Care (CDC) In the November 2011 release of the MY 2011 P4P specifications, Table CDC-A: Prescriptions to Identify Members With Diabetes does not match exactly with Table CDC-A in the 2012 HEDIS volume. Is this an error?

There is an error in the manual. In Table CDC-A: Prescriptions to Identify Members With Diabetes, in the row Miscellaneous antidiabetic agents, the drug Liraglutide should be included in the table.

This error will be corrected in the September 2012 release of the MY 2012 manual.

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.

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 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.