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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9.15.2021 Follow-Up After Emergency Department Visit for Substance Use (FUA) It appears that the medication tables for the Alcohol Use Disorder Treatment Medications List and the Opioid Use Disorder Treatment Medications List needed to identify pharmacotherapy dispensing events in the numerator are not included in the FUA measure. Where can they be found?

The medication tables for the Alcohol Use Disorder Treatment Medications List and the Opioid Use Disorder Treatment Medications List were inadvertently omitted from the measure specifications. The full medication lists are included in the MY 2022 Medication List Directory (MLD). The medication tables can also be found in the following measures: Follow-Up After High-Intensity Care for Substance Use Disorder, Identification of Alcohol and Other Drug Services, Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment.  

This applies to the following Programs and Years:
HEDIS MY 2022

9.15.2021 Acute Hospital Utilization, Emergency Department Utilization and Hospitalization for Potentially Preventable Complications When should rounding occur for variance calculations?

The variance should not be rounded until the final step in the calculation. The final variance calculation for reporting should be rounded to four decimal places using the .5 rule. For example, the PPD and PUCD values are truncated to 10 decimal places, multiplied together at the member level and summed across members for the total. Round the total sum to four decimal places.

This applies to the following Programs and Years:
HEDIS MY 2022

9.15.2021 Guidelines for Calculations and Sampling: Hybrid Method How should the eligible population be reported for hybrid measures if there are optional or required exclusions?

The eligible population for hybrid measures should be reported before the optional exclusions and after the required exclusions for all three hybrid method approaches (refer to Appendix 4 in HEDIS Volume 2). For example, if the eligible population is 100 members and 10 members met optional exclusion criteria, then the reported eligible population value must still be 100.

This applies to the following Programs and Years:
HEDIS MY 2020, 2021

9.15.2021 Acute Hospital Utilization, Emergency Department Utilization and Hospitalization for Potentially Preventable Complications When should rounding occur for variance calculations?

The variance should not be rounded until the final step in the calculation. The final variance calculation for reporting should be rounded to four decimal places using the .5 rule. For example, the PPD and PUCD values are truncated to 10 decimal places, multiplied together at the member level and summed across members for the total. Round the total sum to four decimal places.

This applies to the following Programs and Years:
HEDIS MY 2020, 2021

9.15.2021 Acute Hospital Utilization, Emergency Department Utilization and Hospitalization for Potentially Preventable Complications May covariance values be rounded before using them in the variance calculation?

No. Do not round covariance values for use in variance calculations. Member-level PPD and PUCD should be unrounded in covariance and variance calculations, although truncation to 10 decimal points is applied, per the previous step. NCQA intends to evaluate truncation and rounding logic throughout intermediate calculations to ensure consistency and reduce potential bias in a future publication release.

This applies to the following Programs and Years:
HEDIS MY 2020, 2021

9.15.2021 Well-Child Visits in the First 30 Months of Life (W30) Does a well child visit with an OB/GYN meet criteria for the W30 measure?

Yes, if the OB/GYN is considered to be a PCP by the health plan (i.e., offers primary care medical services). Refer to Appendix 3 of HEDIS Measurement Year 2022 for the definition of “PCP.”

This applies to the following Programs and Years:
HEDIS MY 2022

7.15.2021 Colorectal Cancer Screening (COL) On May 18, 2021 the U.S. Preventive Services Task Force (USPSTF) updated the colorectal cancer screening recommendations to screen for colorectal cancer in adults aged 45 to 49 years. Will NCQA update the COL measure to coincide with the USPSTF recommendations that lower the screening age to 45? If yes, what HEDIS year can we expect this change to be reflected in the measure specs?

NCQA is aware of updates to the US Preventive Services Task Force (USPSTF) guidelines for colorectal cancer screening. Given these updates, NCQA will evaluate potential changes to the HEDIS Colorectal Cancer Screening (COL) measure through input from our clinical and technical measurement advisory panels, the Committee on Performance Measurement and public comment. Any potential changes to the measure resulting from this evaluation would be included in the HEDIS MY 2022 Technical Update at the earliest.

This applies to the following Programs and Years:
HEDIS MY 2021

7.15.2021 Use of Mail Service Organizations for Distribution Requirements Is it considered delegation if an organization uses a mail service organization to meet distribution requirements?

NCQA considers it to be delegation if the organization uses another organization, including a mail service organization, to perform any function not listed in the “Vendor” section of Appendix 2. 
NCQA considers it to be a vendor relationship if the organization uses another organization (e.g., a mail service organization) to perform functions evaluated by the elements or element components listed in the "Vendor" section of Appendix 2.

This applies to the following Programs and Years:
HP 2021

7.15.2021 Use of Mail Service Organizations for Distribution Requirements Is it considered delegation if an organization uses a mail service organization to meet distribution requirements?

NCQA considers it to be delegation if the organization uses another organization, including a mail service organization, to perform any function not listed in the “Vendor” section of Appendix 3. 
NCQA considers it to be a vendor relationship if the organization uses another organization (e.g., a mail service organization) to perform functions evaluated by the elements or element components listed in the "Vendor" section of Appendix 3.

This applies to the following Programs and Years:
MBHO 2021|UM-CR-PN 2021

7.15.2021 Virtual-Only Practitioners If an organization wants to add virtual-only practitioners to its network for services such as behavioral health, does that affect NET 5 and CR 1?

Yes. If an organization adds virtual-only practitioners to its network, the provider directory must indicate that such practitioners are virtual only (i.e., in lieu of a physical office location) to meet NET 5, Element A. Virtual-only practitioners must also be fully credentialed, per requirements in CR 1, Element A.

This applies to the following Programs and Years:
HP 2021

6.29.2021 July 2021 Summary of Updates What changes were made to the PCSP Standards and Guidelines in Version 4?

Topic Update Highlights
Policies and Procedures Added a section on Natural Disasters and Cybercrime.
Policies and Procedures Updated policy on eligibility to clarify that organizations that operate entirely remotely are eligible.
KM 17 Updated the list of CDS examples in the guidance language.
AC 02 Added language to the guidance to clarify that patient inquiries regarding prescription refills or appointment requests are not considered clinical advice.
PM 11 Updated guidance language to detail how Person-Driven Outcome goals can be used to meet the criteria.
QI 01 A, B and C Measures data must be input from the new ‘Measures Reporting’ tile of the Organization Dashboard.

This applies to the following Programs and Years:
PCSP 2019

6.29.2021 July 2021 Summary of Updates What changes were made to the PCMH Standards and Guidelines in Version 7?

Topic Update Highlights
Policies and Procedures Added a section on Natural Disasters and Cybercrime.
Policies and Procedures Updated policy on eligibility to clarify that organizations that operate entirely remotely are eligible.
Appendix 2 – Glossary Added an entry on Behavioral Health Care Clinician.
TC 08/BH 01 Added a note to the guidance language to clarify the required qualifications of a Behavioral Health Care Manager.
KM 20/BH 13 Updated the list of CDS examples in the guidance language.
AC 04 Added language to the guidance to clarify that patient inquiries regarding prescription refills or appointment requests are not considered clinical advice.
CM 06 Updated guidance language to detail how Person-Driven Outcome goals can be used to meet the criteria.
QI 01/ QI 02 Measures data must be input from the new ‘Measures Reporting’ tile of the Organization Dashboard.
Appendix 5 Redesigned Appendix 5 to outline measures reporting including a table of standardized measures now supported.
Distinction in Behavioral Health Integration Clarified that already Recognized practices seeking Distinction have one virtual review.

This applies to the following Programs and Years:
PCMH 2017