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 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 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 Should days covered be capped at the number of days for the measurement period? For example, if a members measurement period is January 1_June 30, 2011 (180 days), and the member fills different prescriptions within the class (different GCNs) on January 1, April 1 and June 15, all with a 90-day supply (195 days within the measurement period), should the days covered be calculated as 180 days?

In your example, the measurement period is 180 days (January 1_June 30). Step 2 of the numerator criteria reads, "within the measurement period, count the number of days the member was covered." In this case, look for covered days from January 1_June 30; in essence, the numerator is being capped. The PDC is not calculated by summing the days supply for pharmacy claims. You may need to set up a time array for each claim, to identify the time frame covered by each fill, then count the number of days in the measurement period that are covered by the time arrays. Thus, the numerator may not exceed the denominator for the person-level PDC calculation. Refer to the attached example for SAS code for arrays.

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 How should organizations count days when a member is covered by a drug in step 2 of the numerator for each rate? The specification states that if prescriptions for the same drug overlap, the prescription start date should be adjusted to be the day after the previous fill has ended. Does this mean that if a member fills a prescription for a 30-day supply of a drug on January 1, 2011, and fills another prescription for the same drug on January 15, 2011, also with a 30-day supply, the days covered is 45 days (30 days for the prescription filled on January 1; 15 days for the drug filled on January 15)?

Sixty days are covered. The first prescription lasts 30 days, starting January 1. If you move the next prescription's start date to the day after the previous fill has ended, it becomes January 31. The end date is March 1. In essence, the start date and the end date of the second prescription both move.

1.16.2012 PR 1: Internet Portal for Notification of Patient Engagement May organizations notify practitioners via an Internet portal for PR 1, Element A, factor 8?

Yes, if the organization's documented process includes how it notifies practitioners that the information is available on the Internet; and if the organization informs practitioners where the information is located. If all practitioners do not have access to the portal, the organizations process must include how it notifies these practitioners of patient engagement.

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 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.

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.

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.