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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1.16.2012 Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women A new exclusion code (ICD 279) was added to the Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women measure, but no guidance was provided on time frame to allow the exclusion.

For this exclusion, look back as far as possible in the members history.

1.16.2012 Proportion of Days Covered by Medications The definition for index prescription date states that the index date should occur at least 91 days before the end of the measurement period. The measurement period is defined as the index date through the last day of the measurement year or until death or disenrollment. How should an organization handle a situation where a members first fill date is January 1, 2011, and the member disenrolls from the plan on March 15, 2011? How should an organization handle a situation where a members first fill date is November 1, 2011? Should the member be excluded from the measure?

In the first scenario, the index date is 74 days prior to the end of the measurement period, so the member should be excluded. In the second scenario, the index date is 61 days prior to the end of the measurement period, so the member should be excluded.

1.16.2012 Proportion of Days Covered by Medications How do you account for claim reversals?

PDC measures are calculated through use of paid, nonreversed claims for target medications. If the drug claims dataset contains claim reversals (and paid claims that were reversed), analysts must ensure that the reversed claims are not used to calculate PDC. Claim reversals can be identified through multiple methods because there may be multiple fields in a drug claim that indicate whether it is a reversal. Many drug claims datasets have a Count field that contains a 1 for a paid claim and a -1 for a claim reversal. The dataset may also have a field called Reversal that contains a Y if the claim is a reversal claim, or an N if it is not a reversal. Reversal claims typically have a negative quantity and a negative cost.

The claim reversal (-1 in the Count field or Y in the Reversal field) may have a Claim Number that is identical to the original claim being reversed. If the Claim Number for the reversal claim is not identical to the Claim Number for the original claim, analysts can create coding logic that will identify the reversed claim as immediately preceding the claim reversal. This latter approach is not usually necessary because most drug claims datasets allow a claim reversal to be linked to an original claim.

1.16.2012 Proportion of Days Covered by Medications For all rates, step 2 of the numerator states that organizations should count the days when a member was covered by at least one drug in the class. However, each rate indicates that there are additional eligible population criteria for the member to have filled at least two prescriptions for the target drug. How can the numerator allow for just one drug in the class to be filled?

At least two prescriptions means that the patient had at least two pharmacy claims for a drug in the target class (this can be refills for the same drug). In the numerator, for a day to be covered, a patient must have a supply on hand of at least one drug in the class.

1.16.2012 Meaningful Use of Heath IT Will PCPs who use certified modules and do some meaningful use measures get credit for the measures?

Yes, although because MUHIT is scored at the measure level, PCPs might receive credit for some measures and not for others.

12.16.2011 Health Appraisal Completion The incentive criteria was revised in 2012. If an incentive is tied to completion of an HA as well as another activity, what category should the incentive be reported under?

If an incentive is tied to completion of an HA as well as another activity, the incentive should be classified as Unknown for WHP 2012 reporting. Please note that example 4 in Table HAC-A was erroneously left in the specification for 2012; this example should be removed from the table.

11.14.2011 Failing to meet the 80% threshold for eligible conditions in PM 1-5 Does an organization with Accredited status lose its status if it submits performance measures, but fails to meet the 80% scoring threshold?

No. An organization with Accredited status that does not meet the 80% scoring threshold for all performance measures retains its status, but will not receive AWPR status.

10.14.2011 Measures with Multiple Indicators Some standardized measures (e.g., Comprehensive Diabetes Care, Chlamydia Screening in Women) have multiple indicators. For PHQ 1, Element A, where scores are based on the percentage of standardized measures , does NCQA count each indicator as a measure, or does it count measures with multiple indicators as one measure?

For PHQ 1 Element A, NCQA counts different indicators as separate measures if they reflect separate care processes; however, NCQA does not count different age stratification rates as separate measures For example, HbA1c testing and LDL-C screening count as two measures even though they are both part of Comprehensive Diabetes Care, but for Chlamydia Screening in Women, the two age stratifications and the total rate can only count as one measure.

10.14.2011 Accredited organizations that fail to submit measures Will organizations that fail to submit DM Performance Measures lose their accreditation status?

It depends. Organizations with Accredited status will not lose that status. Organizations with AWPR status will be downgraded to Accredited status for conditions for which measures are not reported.

9.15.2011 Options for Denied Accreditation What options are available for organizations that have been denied accreditation, but still want to become accredited?

An organization may reapply for accreditation one year after the date when it receives the Denied status, or it may request an Expedited Survey if it has corrected the issues that led to the denial of accreditation. Upon receipt of the organization's written request, NCQA may grant an Expedited Survey in six or nine months of the Denied status if the organization demonstrates that the issues can be corrected within the six-to-nine month time frame and the corrective actions undertaken would raise the organization's accreditation status. (Refer to Policies and Procedures – Section 2: The Accreditation Process, for more information)

9.15.2011 Types of Delegates What types of delegates are reviewed in MA 21?

All delegates that have been delegated activities included in the HP Medicare Advantage Deeming Module are subject to review under MA 21. Delegates that handle non-deemable activities are not within the scope of review for MA 21.

9.15.2011 Text under Complaint and Appeal Categories The following text has been added to Billing and Financial Issues under the Complaint and Appeal Categories subhead: (1) Appeals for denials of out-of-network services where members are balance billed (2) Physicians who code the claim incorrectly (3) Practitioners who balance bill members for services (4) Disputes of deductibles and copayments. Are these new requirements?

No. These are not new requirements. They are examples of billing/financial issues. The text was inadvertently added to the Explanation and will moved to the Examples in the November 21, 2011 Policy Update.