FAQ Directory

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:

P4P made this change to align with HEDIS, but did not consider the unintended impact it will have on POs, which must pull the information from EHRs. Because of the burden to POs, P4P will revert to the prior language for this measure, outlined below.

When identifying the most recent BP reading noted during the measurement year, do not include BP readings that meet the following criteria.

BPs taken during an acute inpatient stay (Table CDC-O)

BPs taken during an ED visit (Table CDC-P)

BPs taken during an outpatient visit where a diagnostic test or surgical procedure was performed (e.g., sigmoidoscopy, removal of a mole) or BPs obtained the same day as a major diagnostic or surgical procedure (e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy) (Table CDC-Q)

BP readings taken by the member.

This applies to the following Programs and Years:

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:

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:

No. Do not include long-acting inhaled beta-2 agonists when calculating the Asthma Medication Ratio measure.

This applies to the following Programs and Years:

No. Data collection methodology must be sound enough to produce valid and reliable results but achievement of significant improvement is not required for QI 10 Element A.

This applies to the following Programs and Years:

No. While the organization may have different complaints and appeal category for business purposes, it must analyze and report both complaint and appeal data by the five specified categories for NCQA purposes. Even if the organization has no complaints or appeals in one or more reporting categories, it must still demonstrate its analysis and report the number of complaints and appeals for all five categories.

This applies to the following Programs and Years:

Yes. If performance issues are identified through organization-wide analysis, the organization must perform an analysis at the practitioner level to identify the cause. Practitioner-level assessment may include the total population or a statistically valid sample.

This applies to the following Programs and Years:

Yes. To receive credit for factor 9, the work plan must address all ten items listed Work Plan in the explanation.

This applies to the following Programs and Years:

No. Organizations must assess members cultural, racial, ethnic and linguistic needs then take actions based on its findings. Leaving out one or more of the required assessment areas would not meet the intent of the element.

This applies to the following Programs and Years:

No. More than one practitioner must be involved in QI program activities. Participating practitioners must represent a broad spectrum of specialties, as appropriate.

This applies to the following Programs and Years:

In MY 2011, health plans may submit results for the Medicare product line and for the commercial product line. Because the Medicare product line is now reported by health plans, the Health Plan Clinical and Testing Measure file layouts have three tabs for the possible reporting scenarios (commercial HMO/POS and Medicare, commercial HMO/POS only, Medicare only).

Scenario 1: The health plan has both commercial HMO/POS and Medicare product lines

Clinical Measure File Layout: Plans that report for both the commercial HMO/POS and Medicare populations must have 66 clinical measure IDs per DMHC ID/Sub Unit, even if an individual PO has only commercial or Medicare enrollment.

Testing Measure File Layout: Plans that report for both the commercial HMO/POS and Medicare populations must have 31 clinical measure IDs per DMHC ID/Sub Unit, even if an individual PO has only commercial or Medicare enrollment.

Refer to Tab (5) Sample HP FileBoth Commercial and Medicare

Examples 1_3: The plan has commercial and Medicare product lines; Pos 11111-00, 22222-03, 22222-05 and 33333-05 also have commercial and Medicare members: the plan submits commercial and Medicare data for these Pos.

Example 4: The plan has commercial and Medicare product lines; PO 44444-01 has only Medicare members: the plan submits Medicare data for PO 44444-01 and populates commercial rows for PO 44444-01 with zero enrollment, zero denominator, zero numerator and rate NB.

Scenario 2: The health plan has commercial HMO/POS product line only

Refer to Tab (6) Sample HP FileCommercial Only: Plans that have the commercial product line only submit data for the commercial product. There are no rows for the Medicare product.

Clinical Measure File Layout: The plan reports 59 clinical measure IDs per DMHC ID/Sub Unit for the commercial product.

Testing Measure File Layout: The plan reports 10 testing measure IDs per DMHC ID/Sub Unit for the commercial product.

Scenario 3: The health plan has Medicare product line only

Refer to Tab (7) Sample HP FileMedicare Only: Plans that have the Medicare product line only submit data for the Medicare product. There are no rows for the commercial HMO/POS product.

Clinical Measure File Layout: The plan reports 7 clinical measure IDs per DMHC ID/Sub Unit for the Medicare product.

Testing Measure File Layout: The plan reports 21 clinical measure IDs per DMHC ID/Sub Unit for the Medicare product.

This applies to the following Programs and Years: