At this time, there are no standardized (i.e., endorsed) measures of cost, resource use or utilization at the physician level.
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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11.15.2012 Cost, resource use or utilization measures Are there standardized measures for cost, resource use or utilization? If there are none, what measures are plans using?
11.15.2012 Standardized Measure Specifications For Element A, if the organizations correction process allows elimination of non-compliant patients from the measure result at the request of the physician, even when those patients are in the standardized measure specification, is the measure still considered to be standardized?
11.15.2012 Organizational accountability Are organizations responsible for confirming the factors in Element F, or is this the responsibility of an external vendor?
For Element F, the organization must demonstrate that it has a process to verify that it has followed the specifications outlined in Element C (e.g., sample sizes, attribution,statistical validity). If the organization uses a vendor to administer the survey, this process may be performed by the vendor, but documentation demonstrating how the element is met must be included for the PHQ Survey.
This applies to the following Programs and Years:
PHQ 201311.15.2012 Survey Tool With PQ 2013 evaluating at the program level, are we required to purchase a tool for every certifiable entity, as in PHQ 2008?
No. An organization is required to purchase a separate survey tool for every program it brings forward. One program operated by an organization such as a corporate parent without variation from region to region may be surveyed using a single tool. An organization that brings forward more than one program must purchase and submit a separate tool for each discrete program it brings forward.
There is a pricing option for derivative programs a derivative program is defined as a program that shares common aspects (e.g. an organization uses the same measures and methodology for a single defined group of physicians but takes a different action (reporting vs. network tiering) as another program its organization brings forward for certification. NCQA can review common aspects once to streamline the survey process (thus the discounted price), although these are distinct programs. To receive a discount, the programs must be brought forward at the same time. Please see the pricing exhibit in the survey agreement. If you need additional information, please contact NCQA Customer Support at (888) 275-7585.
This applies to the following Programs and Years:
PHQ 201311.15.2012 Relative Resource Use (RRU) Measures Are HEDIS RRU measures appropriate for PQ 1 Element B?
10.16.2012 General Guidelines What is the difference between "required" exclusions and "optional" exclusions?
Required exclusions identify members who must be excluded from the measure, regardless of numerator compliance. They are listed as part of the eligible population criteria because members who meet the required exclusion criteria are removed when identifying the denominator of the measure. Optional exclusions should only be used to remove members that did not meet the measure's numerator criteria. Organizations may choose to apply optional exclusions, which are listed separately at the end of the measure specification, or may choose not to apply the exclusions.
This applies to the following Programs and Years:
HEDIS 201310.16.2012 Comprehensive Diabetes Care Can CPT Category II code 4010F be used to identify ACE inhibitor/ARB therapy for the Medical Attention for Nephropathy indicator?
Yes, CPT Category II code 4010F (Angiotensin converting enzyme (ACE) inhibitor or Angiotensin Receptor Blocker (ARB) therapy prescribed or currently being taken) can be used to identify ACE inhibitor/ARB therapy (Table CDC-K) for the Medical Attention for Nephropathy indicator for HEDIS 2014 reporting.
This applies to the following Programs and Years:
HEDIS 201310.15.2012 Standards Does NCQA require specific certifications for organization staff?
While NCQA does not include in requirements that your staff to hold specific certifications for case management, NCQA does have standards requiring organizations to verifying licensure for clinical staff who are required to maintain a license. "Clinical staff" is defined as individuals who are licensed to treat patients. Organizations would determine which certifications are appropriate for staff serving their patient population.
This applies to the following Programs and Years:
CM 201410.15.2012 Standards If some factors are not applicable for our case management program, how would we address it to meet the requirements in CM 2, Element E: Initial Assessment?
For CM 2, Element E, which is a file review element, NCQA is looking for documentation of whether or not you completed the applicable activities listed in CM 2, Element D: Initial Assessment Process. For your program, you would note in your documentation that certain factors are not applicable for that particular patient population.
This applies to the following Programs and Years:
10.15.2012 Basics What is the value of obtaining Case Management Accreditation?
10.15.2012 Excluding ER denial files from the UM denial file review With the elimination of the ER file review (UM 12, Elements B and C), will ER denial files be included in the UM denial file review for UM 4 - 7?
10.15.2012 NHPs going through Full Survey after June 30, 2013. With the change to three Evaluation Options in 2013, what are New Health Plans required to do in their first Full Survey?
Beginning July 1, 2013 New Health Plans will be required to undergo the Renewal Evaluation Option in their first Full Survey. Prior to June 30, 2013, New Health Plan will undergo the Initial Survey as their first Full Survey. The look-back period for the survey will be 12 months.
