FAQ Directory

It depends. If the AR requirement aligns with a PCSP criteria that explicitly specifies a threshold, then that value would be the minimum threshold. However, if a threshold is not explicitly stated in the criteria, then 80% or more is expected to ensure consistent application of the process. Please note that there may be some cases where it’s acceptable for the rate to fall below 80%. 

An explanation in the Note section of Q-PASS is required for practices that report a rate less than 80% for the following criteria: AR-AC 01 [Timely Clinical Advice by Telephone], AR-CC 04 [Tracking Lab Test Results], and AR-CC 05 [Tracking Imaging Test Results].

PCSP 2019

Yes. AR-KM 1 confirms that practices meet PCMH KM 15, in which more than 80% compliance is required for medication lists. A rate less than or equal to 80% does not meet criteria.

PCMH 2017

No. There is no percentage threshold for referral tracking measures. The expectation is that practices track important referrals routinely; if performance is lower than expected, the practice should enter the rationale for their low percentage in the Notes from the Organization section in QPASS.

For example, if data show a 30% return rate, that means 70% of the practice’s referred patients never had a report returned to their PCP. 

PCMH 2017

Yes, if the language specifies that the delegate must meet NCQA requirements (UM 12, Elements A and C, factor 6; UM 13, Element C, factor 5; CR 1, Element C, factor 4; CR 8, Element C, factor 5), template language may be used in the delegation agreement. Language specific to each delegate is not required.

Note: The underlined text is a correction. The previous FAQ referred to the wrong element. 

HP 2022

Yes. The cell should be highlighted to indicate that it is calculated by IDSS.

HEDIS 2022

Yes. Disregard the “N” in Table 1. Organizations may reduce the sample size for the CIS measure using the prior year’s rate or the current year’s administrative rate.

**This FAQ applies to QRS MY 2022.

Exchange 2022

CR 1, Element C, factor 5 requires organizations to have a process for monitoring that policies and procedures are followed for all other factors (factors 1–4) in this element at least annually. Policies and procedures must describe the monitoring process for factor 5.

For CR 1, Element D, the organization submits evidence that it identified, analyzed and acted only on modifications to credentialing/recredentialing information (CR 2 – CR 5) that did not meet the organization’s policies and procedures.

HP 2022

No. Although the organization may set a monitoring goal, NCQA does not require it for UM 11, Elements B and D, factor 2 and CR 1, Element D, factor 2. The intent is that the organization reviews all instances of modifications that did not meet its policies and procedures.

MBHO 2022

For UM 12, Elements A and C:

• Factors 1–5 apply to receipt and notification dates, covered in UM 5 and UM 8–UM 9.
• Factor 6 applies to all UM system data for managing denials and appeals (not only the dates specified in factors 1–5), covered in UM 4–UM 7 and UM 8–UM 9.
• Factor 7 requires a monitoring process that covers compliance with all policies and procedures described in factors 1–6.

HP 2022

For CR 1, Element C:

• Factor 1 applies to verification source information from credentialing and recredentialing cycles, covered in CR 3, Elements A–C.
• Factor 2 applies to modified credentialing verification information from initial credentialing and recredentialing cycles, covered in CR 3, elements A–C.
• Factors 3–4 apply to all information associated with credentialing/recredentialing of practitioners, covered in CR 2–CR 5.
• Factor 5 requires a monitoring process that covers compliance with all policies and procedures described in factors 1–4.

HP 2022

For UM 11, Elements A and C:

• Factors 1–5 apply to receipt and notification dates, covered in UM 5 and UM 8–UM 9.
• Factor 6 applies to all UM system data for managing denials and appeals (not only the dates specified in factors 1–5), covered in UM 4–UM 7 and UM 8–UM 9.

MBHO 2022

Both the organization and delegate must monitor the delegate’s system security controls as part of the delegation oversight requirements and may choose audit as the monitoring method. If auditing is the chosen method, the delegate provides an audit report of modifications that did not comply with its policies and procedures or with the delegation agreement.

The organization is not required to conduct an audit if it determines that the delegate adequately monitored and reported noncompliant modifications, but must provide documentation (a report, meeting minutes or other evidence) that it reviewed and agreed with the delegate’s findings. If the organization determines that the delegate did not adequately monitor noncompliant modifications, it must conduct its own audit of the delegate’s system controls.

The organization must submit its documentation and the delegate’s documentation as part of the survey.
 

MBHO 2022