FAQ Directory

No. The “Explanation” and the “Related information” sections of UM 5, Elements A, C and E still apply to UM 5, Elements B, D and F, respectively. All applicable information was moved to the relevant elements for HPA 2020.

HP 2019

The evidence must specifically reflect the practice’s patient population. Standalone practices whose PFAC only includes patients and family members from the practice may use it to meet QI 04B. For practices that are a part of an organization with other primary care practices under the same umbrella, a shared PFAC would not meet QI 04B. While an organization with a shared PFAC in most cases cannot use it as evidence for QI 04B, it may be used it to demonstrate shared evidence to meet elective criteria TC 04 (2 credits) and QI 17 (2 credits).

PCMH 2017

No, increasing survey response rate is important in obtaining more representative patient feedback, but would not meet the intent of QI 08 or AR QI 03. The response rate is part of the platform for obtaining the feedback, while the measure for these criteria should be improving the feedback itself.
 

PCMH 2017

No, neither secure, electronic fax noR secure email would meet the intent of CM 09. For CM 09, the practice must demonstrate its capability to make their patient's care plans available securely to other care settings, such as hospitals, specialists, or other care facilities that could be managing patient care. This availability should be at the time the patient is seen, including after hours, and as such should not involve reaching out to the practice for the information to be sent. The way in which this care plan is shared may vary and NCQA is not prescriptive, but examples include sharing care plans via shared medical records, HIEs or other shared systems that enable staff from different care settings to view the patient's care plan for continuity and optimal care coordination while the patient receives care from multiple settings.
 

PCMH 2017

The organization does not need to have value-based payments for every month of the look-back period. It reports:

• As the numerator: The value-based payments made during the look-back period, and
• As the denominator: All payments (including fee-for-service) made during the entire look-back period.

For example, the denominator is 12 months of all payments, but if there are 3 months of value-based payments in the look-back period, the numerator is the 3 months of value-based payments.

HP 2019

Except for plans in Puerto Rico, which report all members in the “Unknown” category, it is expected that the member count in this category will be fewer than 10. Plans should determine why members are reported as “Unknown” and be able to explain the reason to their auditor.

This category should not be used for members who are disenrolled for the 2019 calendar year and consequently have no record in the December 2018 Monthly Membership Detail File. Use the October and November files for these members.

HEDIS 2019

General Guideline 25 in HEDIS Volume 2 explains that benefits are not assessed at the service level. Assessment of benefits must follow the measure specifications under the Benefit section of the Eligible Population criteria. Organizations may not assess benefits at a service level for an NB (No Benefit) audit designation. 

For example:

·    If the organization offers a pharmacy benefit but does not cover a specific medication class, the member has a pharmacy benefit and is included in the applicable measures requiring this benefit.

·    If the organization offers a mental health benefit but does not cover inpatient visits, the member has a mental health benefit and is included in the applicable measures requiring this benefit, unless the measure benefit requires inpatient care, per the Eligible Population benefit requirements (e.g., Follow-up After Hospitalization for Mental Illness requires both inpatient and outpatient mental health coverage).

HEDIS 2019

Referencing benefit documents such as the member handbook or Certificate of Coverage by title alone is not specific enough to meet the requirement. Because benefit documents are often large and complex, the organization must direct members to the specific location of the information, either by section title or page number.

The reference must still support the organization’s decision and relate to the reason for the request

HP 2019

Factors 7-13 should be scored as “Met” for upheld denials sent to MAXIMUS.

HP 2018

No. As a general rule, examples should be used as a guide. Examples of questions for PHM 5, Element F that are not prescriptive, but address each requirement listed in the Explanation, include:

1.  How satisfied are you with the information provided about the overall case management program?

2.  How would you rate your experience with the case manager overall? With the program staff?

3.  Did the case manager and other program staff treat you with courtesy and respect?

4. Was the information provided to you useful?

5. How well were you able to follow the recommendations provided to you by the case manager?

6. Were you able to achieve your health goals in your case management plan?

HP 2019

No. The organization is not required to include all these areas in its analysis, but at a minimum, must evaluate rates of unplanned admissions to facilities and emergency room visits to identify areas for improvement.

CM 2019

Participating in an HIE can help practices demonstrate PCMH criteria; however, connection alone does not demonstrate the evidence needed to meet the following criteria. Practices must demonstrate how they use the HIE to meet each criterion. Utilization of an HIE could help meet the following criteria:
 

PCMH 2017