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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11.16.2023 MY 2023 Race and Ethnicity Stratification (RES) HEDIS Compliance Audit Requirements Are there new audit requirements for race and ethnicity stratification reporting for MY 2023?

No. Volume 5: HEDIS Compliance Audit MY 2023 does not include new requirements for reporting race and ethnicity. Consistent with MY 2022, these data are addressed in the HEDIS Roadmap. Auditors must confirm that organizations provide a complete Roadmap response, and review all attachments describing data flow, layout and transformation. Roadmap Section 6, Question 6.3J requires organizations to describe the sources they use, their processes for disaggregating race and ethnicity fields, their data source reconciliation and prioritization processes and the percentage of members with available data.  

NCQA introduced a direct data threshold of ≥20% for Race/Ethnicity Diversity of Membership (RDM) in the 2024 Health Plan Ratings scoring methodology. Please note that this is independent from the race and ethnicity stratifications, and should not impact audit designations. There are no bias thresholds for the race and ethnicity stratifications in Volume 5.

HEDIS 2023

11.15.2023 Codes for Race and Ethnicity Stratification (RES) Are LOINC codes used to identify race and ethnicity?

No. Codes to identify race and ethnicity resemble some LOINC codes (i.e., the same format), but are derived from a code system developed by the U.S. Centers for Disease Control and Prevention (CDC).
The code is the same across terminologies in multiple instances. NCQA recommends that organizations establish data quality controls to avoid inadvertent data reporting errors. For example, “2106-3” could result in errors if used incorrectly:

  • 2106-3 = “White” (CDC Race and Ethnicity).
  • 2106-3 = “Choriogonadotropin (pregnancy test) [Presence] in Urine” (LOINC).

HEDIS 2024

11.15.2023 HEDIS Roadmap Documentation Requirements for Aggregators What HEDIS Compliance Audit Roadmap documentation is required by health plans for data sources provided from an aggregator (e.g., health information exchange)?

It depends:

  • For data streams provided by aggregators with a current approved validation status in the NCQA Data Aggregator Validation program, only Roadmap Section 5 from the plan is required. 
  • For all other data streams provided by aggregators that are not validated in the DAV program, a Roadmap Section 5 from the plan and Section 5a from the aggregator are required.

NCQA maintains an online directory of entities with validated data streams.

HEDIS 2024

11.15.2023 Using SAM.gov for Medicare/Medicaid Sanctions Is SAM.gov an acceptable source for verifying Medicare and Medicaid sanctions?

Yes. Organizations may use SAM.gov to verify Medicare and Medicaid sanctions for CR 3, Element B, factor 2 and CR 5, Element A, factor 1.

HP 2023

11.15.2023 Members Recommended for Routine Cervical Cancer Screening The Cervical Cancer Screening (CCS and CCS-E) measures include the following criteria to identify members recommended for routine cervical cancer screening:
• Administrative Gender of Female (AdministrativeGender code F) any time in the member’s history.
• Sex Assigned at Birth (LOINC code 76689-9) of Female (LOINC code LA3-6) any time in the member’s history.
• Sex Parameter for Clinical Use of Female (SexParameterForClinicalUse code Female-typical) during the measurement year.
What data sources can be used to identify these members?

When reporting CCS-E, all three methods may be used, using any data source. When reporting CCS, use only administrative data (Administrative Gender of Female [AdministrativeGender code F] any time in the member’s history) to determine members recommended for routine cervical cancer screening.
Where supplemental data may be used for CCS remains the same for MY 2024. Supplemental data may not be used for denominator criteria, except in required exclusions.

HEDIS 2024

11.15.2023 CVO: Using SAM.gov for Medicare/Medicaid Sanctions Is SAM.gov an acceptable source for verifying Medicare and Medicaid sanctions?

Yes. Organizations may use SAM.gov to verify Medicare and Medicaid sanctions for CVO 11, Element A and CVO 14, Element C.

CVO 2022

11.15.2023 Excluding Laboratory Claims (Claims with POS Code 81) Will instructions to exclude laboratory claims (claims with POS code 81) be added to additional measures and value sets in the Technical Update memo?

Yes. We anticipate the laboratory claim exclusion will be added to the following measures and value sets in the Technical Update memo:
AMR:    Step 2 of the event/diagnosis (Asthma Value Set)
GSD:    Numerators (HbA1c Test Result or Finding Value Set)
EED:     Event/diagnosis (Diabetes Value Set)
OMW:   Step 2 of the event/diagnosis (Fractures Value Set)
SSD:     Numerator (HbA1c Test Result or Finding Value Set)
SMD:    Numerator (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
SMC:    Numerator (LDL-C Test Result or Finding Value Set)
IET:      Step 2 of the event/diagnosis (Alcohol Abuse and Dependence Value Set; Opioid Abuse and Dependence Value Set; Other Drug Abuse and Dependence Value Set)
APM-E: Numerators (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
DSF-E:  Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Depression Value Set)
DMS-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
DRR-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
ASF-E: Exclusions 1 (Alcohol Use Disorder Value Set; Dementia Value Set)

HEDIS 2024

11.15.2023 Notice of Medicare Non-Coverage (NOMNC) Denials For the UM file review universe, should plans include concurrent denials for Medicare members that involve issuance of a Notice of Medicare Non-Coverage (NOMNC) document?

No. Notice of Medicare Non-Coverage (NOMNC) denial files are out of NCQA’s scope of review and should be excluded from the UM file universe.

HP 2023

10.16.2023 Palliative Care Timeframe for Risk of Continued Opioid Use (COU) The time frame for palliative care (bullets 2 and 3 under “Required exclusions”) in the COU measure states to identify palliative care during the measurement period. Is this correct?

No. The correct time frame for identifying palliative care is “at any time during the 365 days prior to the IPSD through 61 days after the IPSD.” This correction will be in the MY 2024 Technical Update.

HEDIS 2024

10.16.2023 Race and Ethnicity Stratification for Childhood Immunization Status (CIS) and Cervical Cancer Screening (CCS) Race and ethnicity stratification criteria are listed for CIS-E but not for CIS, and for CCS-E but not for CCS. Is this intentional?

Yes. Race and ethnicity stratification is not required for traditional reporting of CIS and CCS. The race and ethnicity stratifications are reported when using the Electronic Clinical Data Systems reporting standard for CIS-E and CCS-E.

HEDIS 2024

10.16.2023 Explanation of Benefit (EOB) The digital measure packages for MY 2024 include “Explanation of Benefit” (EOB) criteria. What does that mean?

Although HEDIS digital measure logic references “Explanation of Benefit (EOB),” this is not referenced as a data source in HEDIS Volume 2. In FHIR, the EOB resource represents claims that have been adjudicated, and includes data elements from both Claim and ClaimResponse. The digital logic was written to include the Claim/ClaimResponse resource for claims that are still processing; the ExplanationOfBenefit resource is for claims that are adjudicated.

HEDIS 2024

10.16.2023 Updated: MBHO: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?

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.

MBHO 2023