FAQ Directory

Yes. Organizations may submit the mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit. This is not required to be specified in the delegation agreement.

This applies to the following Programs and Years:

Yes. Using UM 12: Delegation of UM as an example, the following describes factors that would be considered NA:

UM 12, Element A: Delegation Agreement

• Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution
  • Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance.
  • Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
• Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.

UM 12, Element C: Review of the UM Program

• Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates
• Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
  • Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).

Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit. This must be specified in the delegation agreement.

Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.

This applies to the following Programs and Years:

Yes, the following CAQH question meets the intent of the requirement in  CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2:

CAQH provides additional information regarding what "currently" means that aligns with language in the explanation of CVO 12, Element A, factor 2 and CVO 13, Element A, factor 2 that the organization may use more general or extensive language to query practitioners about impairment.

This applies to the following Programs and Years:

The age stratifications listed under “Characteristics” are incorrect; they should be 46-50 and 51-75. This correction will be in the MY 2024 Technical Update. The age stratifications listed in the Data Elements for Reporting tables are correct.
 

This applies to the following Programs and Years:

There has been an update to the PCMH 2023 annual reporting requirements. AR TC 1 ( Staff Involvement in Quality Improvement) and AR CC 1 ( Hospital and ED Coordination) will now require additional documentation to demonstrate practices are meeting requirements. NCQA is requesting a documented process and evidence of implementation in addition to attestation for this criteria. All practices will have the ability to upload necessary documentation in Q-PASS by the end August. Until then, your RP manager may reach out to request additional documents.
 

This applies to the following Programs and Years:

An example of expected outcome/prognosis is typically clinically based. Expected outcome/prognosis is what the expected outcome of complying with the care plan would be. You can think about it as if a patient follows all instructions of the care plan what you are expecting to happen (e.g., their A1C/BMI/stroke risk etc. will decrease). Generally, we see practices differentiate treatment outcome/prognosis as a more clinical metric, for instance lowering A1C by 2 points etc.  

Treatment goals are more lifestyle choices or outcomes for the patient, such as eating more vegetables or getting enough exercise to be able to walk around the block etc.  

All of these elements are incorporated into the care plan: a problem list, expected outcome/prognosis, treatment goals, medication management and a schedule to review and revise the plan, as needed.  

This applies to the following Programs and Years:

Yes. If medical records document that the member meets exclusion criteria, the member is excluded from the sample and replaced with a member of the oversample.
 

This applies to the following Programs and Years:

The KED measure provides actionable information for chronic kidney disease identification and management. General guidance from our experts is that tests included in the measure should align with guideline recommendations from the American Diabetes Association and the National Kidney Foundation. For this reason, only quantitative uACR tests are allowed and semi-quantitative tests are not considered measure compliant. Removing LOINC code 32294-1 from the value set maintains these coding parameters.

This applies to the following Programs and Years:

Organizations cannot use PCS responses that are over 3 years old. If your question relates directly to a measure specification or general guideline that was revised from a previous measurement year, submit the question rather than using the answer in PCS.

This applies to the following Programs and Years:

NCQA requires practitioners to attest to their lack of present illegal drug use, but not to past drug use or history of drug use.

Organizations are not required to refer exclusively to the present; therefore, an organization may choose to ask about both present and past drug use.

This applies to the following Programs and Years:

No. Members with documentation of “hysterectomy” and documentation indicating that they no longer need Pap testing/cervical cancer screening must remain in the measure for MY 2023 reporting. Members with documentation of a “vaginal pap smear” and documentation of “hysterectomy” must also remain in the measure for HEDIS MY 2023 reporting. This is because the documentation must match the clinical specificity of the codes in the value sets and there are no codes that are clinically synonymous with these examples.
There must be evidence of a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix in order to meet required exclusion criteria for MY 2023 reporting.
Documented “vaginal hysterectomy” or “complete/total/radical hysterectomy” that matches a definition in applicable value sets may be used to meet criteria, subject to auditor approval.
 

This applies to the following Programs and Years:

Yes. Organizations may use an API to access data from a primary or approved source, and must provide documentation that the API collects information only from primary or approved sources.

Organizations that use an API must still meet the “Appropriate documentation” requirements in CR 1, Element A, including documentation that the organization's staff reviewed the information.

As noted in an FAQ from February 15, 2023, use of another entity’s software to collect credentialing information is not considered delegation unless the entity also reviews the information on the organization’s behalf.

This applies to the following Programs and Years: