Yes. We sent communication to plans, auditors, vendors, physician groups, purchaser groups and state and federal agencies.
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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7.16.2012 Medical Record Review Validation Has NCQA communicated the changes to the MRRV process?
7.16.2012 Medical Record Review Validation How can we prepare for the changes listed in the MRRV memo?
Communicate timeline changes and processes to staff; to your network of providers; to leadership at your plan; to medical record and copy vendors; and to your software vendor. Develop a plan and prepare with adequate resources for the HEDIS season. Add HEDIS performance guarantees with vendors to ensure clear understanding of goals and timelines.
This applies to the following Programs and Years:
HEDIS 20137.16.2012 Medical Record Review Validation Does NCQA expect a decrease in rates with this new policy?
7.16.2012 Medical Record Review Validation Does the audit timeline have a new MRR completion date?
Yes. For HEDIS 2013, NCQA will enforce a medical record review deadline of May 15 (the previous deadline was May 10). No charts will be accepted past this deadline, when auditors will begin to review records. Holding all plans to the same timeline ensures comparability among submissions.
This applies to the following Programs and Years:
HEDIS 20137.16.2012 Medical Record Review Validation Why did the MRRV policy change?
NCQA continually reviews the audit process to ensure that it meets all applicable reporting requirements and is the rigorous process expected by all stakeholders.
Responding to increasing pressure from incentive programs, and with CMS input, over the past year NCQA developed the audit policy described in the June 19 MRRV memo. This change will make a more exacting process that ensures enough time for auditing and reporting valid results.
This applies to the following Programs and Years:
HEDIS 20137.15.2012 Determinations on non-creditable coverage requests If a member does not have creditable coverage, are decisions on pre-existing conditions considered medical necessity determinations?
No. If a member does not have creditable coverage, or does not have enough coverage to offset the entire pre-existing condition exclusionary period, the denial is not considered a medical necessity determination and should not be included in the UM denial file review. However, the denial may be appealed, and should be included in the appeal file review.
This applies to the following Programs and Years:
7.15.2012 Extending the time frame for initial assessment How many failed attempts to locate or communicate with a member must be made before an organization can exclude the member from a complex case management program?
A member who cannot be located or communicated with after three or more attempts over a 2-week period may be excluded from complex case management, and the file may be excluded from review. The organization must document attempts to contact the member by various mechanisms (telephone, letter, e-mail or fax) and through authorized caregiver channels.
This applies to the following Programs and Years:
5.16.2012 Proportion of Days Covered by Medications (PDC) For the PDC measure, if a 30 day prescription is filled before the start of the measurement year but spills over into the current measurement year, how is it counted? For example, if a member fills a 30-day prescription on 12/15/10, does it count for MY 2011, for the 15 days that the prescription lasts into MY 2011?
No. A fill date from the previous measurement year is not included in current measurement year calculations. The text on page 180 of the MY 2011 P4P publication, under Index prescription date (IPD), should read [the IPD is the] first fill date during the measurement year. The member in your example is ineligible because the first fill date does not occur in the current measurement year.
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 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 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?
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.
