FAQ Directory

Categorize members in the “Any Services” category based on their age as of the first eligible encounter in any service category.

This applies to the following Programs and Years:

Any practitioner who provides care to or makes care decisions for or about a member’s care is part of the care team. Please note, if a measure has a practitioner type requirement the services required by the measure must still be performed by the appropriate practitioner type. However, the care team requirement for the data to qualify for ECDS reporting is not restricted by the practitioner type requirement.

This applies to the following Programs and Years:

Yes. Plans may use administrative data to report HEDIS ECDS measures. Administrative data are a relevant data source and are one of four categories of data for ECDS reporting. If a plan’s administrative data files contain all the information it needs for a measure, it does not need additional data.

This applies to the following Programs and Years:

No. Plans do not need to be able to populate information directly into a provider EMR to meet this requirement. Plans can meet the requirement if they can provide requested information (phone, secure email, direct feed, provider portal, file request) to providers who are treating their members. Plans should have documented processes for providing information on how this works to be reviewed as part of the audit.

This applies to the following Programs and Years:

No. Although this plan type may have a slight advantage in accessing medical records because of its integrated system, EMRs do not necessarily contain comprehensive information on individuals. Many other data sources qualify as ECDS data sources, and plans are encouraged to utilize every reliable source of member data.

This applies to the following Programs and Years:

Because the SES assessment is new and requires files not normally used for NCQA’s measure calculations, we have explored options for reporting members with these scenarios, and we think there are options for these data.
NOTE: NCQA’s Certification program tests one record per member based on the MMDDF.

• Option 1: If you are using MMDDF and one month has multiple rows for a member with different values in one row or more, sum the values and use the result to compare to the other 3 months. Remember that what is important is whether the number is > 0 or it is < or = 0. See this example:

This member is counted as LIS eligible: the sum of October = 35.50, the sum of November = 35.5, and December = 35.50 (all months are >0).

• Option 2: If you have access to the LIS History (LISHIST) File, it can be used to determine LIS eligibility. CMS describes the file as the most complete picture of LIS eligibility over a period not to exceed 36 months. This data file includes LIS activity for past, present and future enrollees. A full copy of the Plan-Communications-User-Guide-v122-August-31-2018, which describes the file, can be found at https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/Plan-Communications-User-Guide-v122-August-31-2018.pdf. Below is an example of the corresponding records in the LISHIST file for the member shown above.

 
This file clearly shows that the member was LIS eligible for the HEDIS 2019 measurement year (calendar year 2018). If you have access to this file, it may be the easiest, most accurate data to use.
 
NOTES:

1. If the LowIncomePeriodEndDate is blank, the member is still eligible.
2. Plans should use a copy of this file from December 2018 or later.

 
*This same FAQ was posted on November 15, 2018 but was updated in the December 2018 FAQ posting. In the above “NOTES” section, it used to read that plans should use a copy of the file from January 2019 or later. This date was corrected to December 2018 or later.
 

This applies to the following Programs and Years:

EMRs are limited in the amount of longitudinal information they contain for any one patient. Many data sources meet ECDS requirements. Plans have access to a wealth of information from across a much larger network than any single provider. ECDS is designed to encourage plans and providers to seek alternative sources of data (already being collected) to fill gaps in knowledge about a person’s health care experiences and future requirements.

This applies to the following Programs and Years:

Yes. As stated in General Guideline 30, both standard and nonstandard supplemental data files must contain all data elements required by the hybrid specification, regardless of the reporting method used (administrative or hybrid). However, for HEDIS 2019, NCQA makes an exception for only standard supplemental data files and for only the Adult BMI Assessment (ABA) and Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) measures.

Because the values (height, weight) used to calculate BMI are often stored in EMRs and not included in data extracts, NCQA does not want to penalize plans for not having these data elements in their data files. Auditors may approve standard supplemental data files that include only the date and the BMI value or percentile.

For the WCC nutrition and physical activity counseling indicators, a date of service and an applicable code from the VSD counts as compliant.

NCQA is evaluating the standard supplemental data requirement for all other hybrid measures for HEDIS 2020.

This applies to the following Programs and Years:

QI 6 requires organizations to collect data from all sources of member complaints and appeals, including UM coverage appeals addressed in UM 8–UM 9 and noncoverage appeals addressed in RR 2.
Note: Data collected and analyzed before February 15, 2019, will be accepted as meeting the requirement even if not all types of appeals are included. Data collected and analyzed on or after this date must comply with the requirement stated in the FAQ.
If your organization collected and analyzed data before February 15, 2019, and interpreted the requirement as applying to only one type of appeal, notify the surveyor at the start of the survey so the misinterpretation does not affect scoring.
 

This applies to the following Programs and Years:

A value is different if it is either < or = 0 OR > 0. For the last 3 months of the CE period:

• Count the member as receiving an LIS payment if 2 of the last 3 months are >0, even if the values are different.

• Count the member as NOT receiving an LIS payment if 2 of the last 3 months are < or = 0, even if the values are different.

This applies to the following Programs and Years:

Yes, if the interaction meets criteria based on the measure specifications. The caregiver is not required to be designated as the patient’s legal guardian for the interaction to count toward the measure.  

This applies to the following Programs and Years:

Yes. When the PCP or ongoing care provider is the discharging provider, they must document the required discharge information specified in the measure. This must be done in the patient's outpatient medical record on the day of discharge or on the following day.

This applies to the following Programs and Years: