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 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:

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 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.

This applies to the following Programs and Years:

5.15.2012 Appeal notices in a culturally and linguistically appropriate manner What does NCQA look for in an appeal notification that meets the "culturally and linguistically appropriate manner" requirement?

"Culturally and linguistically" appropriate refers to the organization providing notices of the appeal process to non-English-speaking members, in languages appropriate to members.

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:

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 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:

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:

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.

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 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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years: