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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5.15.2012 Verification of certification for an unrecognized board Does NCQA only accept ABMS and AOA sponsored boards as verification sources? What does NCQA require for verification of boards from non-ABMS or non-AOA boards if the practitioner claims to be board certified?

No. With the exception of ABMS or AOA sponsored boards, NCQA requires organizations to determine and list specialty boards they accept within their credentialing policies and procedures. At a minimum, at least annually, organizations must obtain written confirmation from the specialty board that it performs primary-source verification of education and training. A specialty board that provides annual written confirmation that it conducts primary source verification of education and training can be used as an acceptable source for verification of education and training if the organization names the specialty board in its policies and procedures.

The organization must verify board certification status for any practitioner claiming to be certified by an ABMS or AOA sponsored boards, or by a specialty board recognized by the organization.

This applies to the following Programs and Years:

5.15.2012 Clinical quality measures across programs May organizations use the same clinical quality measure for each program brought forward for accreditation?

Yes. Organizations may use the same clinical quality measure for each program if the measure is relevant to each program's population. Each program's population must be measured separately.

This applies to the following Programs and Years:

5.15.2012 Collecting feedback from program participants Is an organization required to collect feedback from all programs and all program participants, or may the organization choose from whom to collect feedback?

Organizations must include all programs or population segments to assess for WHP 9, Element A.

Data collection must be across all programs and include eligible participants. If an organization uses a sample, the sample must be randomized to give all eligible participants an equal chance of being included.

This applies to the following Programs and Years:

5.15.2012 Bylaws in place of Credentialing Policies and Procedures May a hospital's by-laws serve as credentialing policies and procedures?

Yes. An organization may use its bylaws to meet the credentialing policies and procedures if the bylaws include all credentialing requirements of the element.

This applies to the following Programs and Years:

5.15.2012 Appropriate form of "written acknowledgement" Is e-mail correspondence between the health plan and an NCQA-certified organization acceptable as "written acknowledgment" when a formal delegation agreement is not necessary?

Yes. E-mailed correspondence suffices as written acknowledgment if it adequately outlines the delegated responsibilities of the certified organization.

This applies to the following Programs and Years:

5.15.2012 Remove notice of new appeal reviewer from the denial letter For UM 7, Elements D and G, factor 2, must the explanation of the appeal process include notice that a new, nonsubordinate reviewer will be appointed?

No. The denial notice does not need to include notification that a new, nonsubordinate reviewer will be appointed; however, the organization must include this requirement in its appeal policies and procedures to meet UM 8, Elements B and C, factor 5, and include it in applicable appeal files to meet UM 9, Element C.

This applies to the following Programs and Years:

4.16.2012 Use of Imaging Studies for Low Back Pain (LBP) In the November 2011 release of the MY2011 P4P Manual, the table LBP-D contains an invalid CPT code, 72011. Is this an error?

Yes. The first CPT code in the table should be 72010. This error will be corrected in the September 2012 release of the MY 2012 manual.

This applies to the following Programs and Years:

4.16.2012 Meaningful Use of Health Information Technology (MUHIT) In the November 2011 release of the MY2011 P4P Manual, the examples for scoring of the MUHIT domain in the Description and Domain Structure sections (pp 114 and 115) seem to have incorrect calculations. Is this an error?

Yes. The example on page 114 should read as follows:

100 out of 100 PCPs meet the criteria = 100%

_ 5 points for certified and 3.75 for non-certified

25 of 100 certified = ((25% * 5) = 1.25)

75 of 100 non-certified = ((75% * 3.75) = 2.81)

Total points = ((1.25+ 2.81) = 4.06)

The example on page 115, in the Point allocation for POs using ONC-ATCB certified software section, should read as follows:

For example, if a PO earned 60 points, its overall calculated P4P score would be 18. Scores are rounded to the nearest whole number.

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

This applies to the following Programs and Years:

4.16.2012 Proportion of Days Covered by Medications (PDC) The Eligible Population criteria state that continuous enrollment for PDC is the index prescription date (IPD) through the end of the measurement year or until death or disenrollment, and that there is no allowable gap. Are members with two separate enrollment periods that meet the 90 day requirement excluded because of the gap in enrollment, or are they counted as two separate measurement periods?

Because there are no allowable gaps in this measure, exclude members who were not continuously enrolled, including members who had more than one 90+ day measurement period.

This applies to the following Programs and Years:

3.16.2012 Encounter Rate Threshold for Clinical Measures Table ENR-F Option A states to use the CMS ASC Approved HCPCS Codes and Payment Rates file and to only use the spreadsheet titled, "Addendum AA_ASC Covered Surgical Procedures (ASC_AddAA.csv) for October 2011". This exact file name is not found in the zip file on the CMS website. Please confirm the file and tab that should be used.

The file name has been updated on the CMS website. To reflect this change, the note under Table ENR-F should read as follow: * These codes can be found on the CMS Web site (http://www.cms.hhs.gov/ASCPayment/11_Addenda_Updates.asp#TopOfPage/). Click October 2011 ASC Approved HCPCS codes and Payment Rates. Use only the spreadsheet titled, Oct11_ASC_Add_AA-BB-DD1_ExtAct.xlsx, and the tab titled Oct11_ASC_AddAA-ExtAct. Only use 5-digit all-numeric CPT codes (Level 1 HCPCS) in the spreadsheet; do not include any codes with an alpha value. This update will be reflected in the September 2012 release of the MY 2012 manual.

This applies to the following Programs and Years:

3.16.2012 Proportion of Days Covered by Medications (PDC) In the November 2011 release of the MY2011 P4P specifications, the wording under Definitions and Eligible Population is confusing. The definition of the Index Prescription Date (IPD) states that the index date should occur at least 91 days before the end of the measurement period, but under Continuous Enrollment, the manual states that the IPD must occur at least 91 days prior to the end of the measurement year. Should we be looking back from the end of the measurement period or the end of the measurement year?

The Index Prescription Date (IPD) should occur at least 91 days before the end of the measurement period, as stated in the definition of IPD. The Continuous Enrollment section should refer to the measurement period, for both self-reporting POs and for health plans.

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

This applies to the following Programs and Years:

3.16.2012 Avoidance of Antibiotic Treatment for Adults With Acute Bronchitis (AAB) In the November 2011 release of the MY 2011 P4P specifications, Table AAB-E: Antibiotic Medications does not match exactly with Table AAB-D in the 2012 HEDIS volume. Is this an error?

There is an error in the manual. In Table AAB-E: Antibiotic Medications,

the first two rows, 5-aminosalicylates and Amebicides should not be in the table,

in the row Aminoglycosides the drug Neomycin should not be in the table,

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

in the row Miscellaneous antibiotics the drug Vancomycin should be included in the table,

the row sulfamethoxazole-trimethoprim DS should not be in the table,

in the row natural penicillins the drug Penicillin G benzathine should be included in the table,

in the row Third generation cephalosporins, the drugs Cefditoren and Cefpodoxime should be included in the table,

in the row Third generation cephalosporins, the drug Cefoperazone should not be in the table.

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

This applies to the following Programs and Years: