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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

9.15.2011 Types of Delegates What types of delegates are reviewed in MA 21?

All delegates that have been delegated activities included in the HP Medicare Advantage Deeming Module are subject to review under MA 21. Delegates that handle non-deemable activities are not within the scope of review for MA 21.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

9.15.2011 Options for Denied Accreditation What options are available for organizations that have been denied accreditation, but still want to become accredited?

An organization may reapply for accreditation one year after the date when it receives the Denied status, or it may request an Expedited Survey if it has corrected the issues that led to the denial of accreditation. Upon receipt of the organization's written request, NCQA may grant an Expedited Survey in six or nine months of the Denied status if the organization demonstrates that the issues can be corrected within the six-to-nine month time frame and the corrective actions undertaken would raise the organization's accreditation status. (Refer to Policies and Procedures – Section 2: The Accreditation Process, for more information)

This applies to the following Programs and Years:

5.16.2011 Removal of Chronic Care Improvement Projects (CCIP) and Quality Improvement Projects (QIP) from Deeming CMS recently announced that CCIPs and QIPs are no longer deemable. Will you continue to review organizations against these requirements?

No. We have been instructed by CMS to stop reviewing these requirements. Effective immediately, MA 13 and MA 18 will be scored NA.

This applies to the following Programs and Years:

5.16.2011 General Guidelines If a DM organization does not meet the 15,000 minimum enrollment threshold, may it submit DM measure results to NCQA to be scored as a part of accreditation?

Yes. NCQA is lowering the enrollment threshold for DM 2012 and allowing optional reporting for organizations that do not meet this requirement. Because the threshold will change next year, DM organizations that do not meet the threshold may report in 2011 and earn the Accredited With Performance Reporting status.

This applies to the following Programs and Years:

5.16.2011 Use of Performance-based Improvement Module (PIM) Element A states that If an organization takes action based on physician completion of an ABMS or AOA board performance-based improvement module generally in conjunction with maintenance of certification) at least every two years, those activities may be used as a quality measure for the purposes of meeting this standard. When counting the quality measures for Element A, for how many measures does NCQA award credit (e.g. for each measure in the PIM or for each PIM)?

Regardless of the number of measures within a PIM, each PIM counts as one standardized measure for PHQ 1, Element A. This is consistent with the current language in the PHQ standards and guidelines (i.e., activities may be used as a measure). To receive credit for using PIMs and for the survey team to verify that the Board requires a PIM as part of certification maintenance, the organization must list in the Survey Tool's Element A Measure Worksheet: (1) the PIMs on which it bases the action; (2) list the source of the measures as Specialty Medical Boards; and (3) provide a direct link to the Board where the PIM and its measures can be found.

This applies to the following Programs and Years:

4.16.2011 Quality assessments for Organizational Providers Must organizations conduct an onsite quality assessment of non-accredited providers?

No. Organizations must conduct a quality assessment of nonaccredited providers, but the quality assessment does not need to occur onsite for MA Deeming Surveys.

This applies to the following Programs and Years: