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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Yes, unhealthy behaviors can be the result of parent behavior but ultimately, we're looking for the unhealthy behaviors demonstrated by the patient (child). Secondhand smoke may be a direct example of a parent’s behavior affecting the child’s health and poor oral hygiene may be a child’s unhealthy behavior, but could result from lack of parental oversight or health literacy.
Care coordination resources, including a sample patient care plan can be found at:
https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/Pages/Care-Coordination.aspx
National Center for Medical Home Implementation Building Your Medical Home Guide:
https://medicalhomes.aap.org/Pages/Managing-Your-Patient-Population.aspx
https://medicalhomes.aap.org/Documents/PediatricCarePlan.pdf
NICHQ Care Plan Template: https://www.nichq.org/resource/nichqs-care-plan-template
Pediatric practices are not penalized for not sharing information with parents if the adolescent requests that information not be shared, but applicants must explain the exclusion of adolescent patients in the associated documentation. The system must include only legitimate requests for information based on state and federal confidentiality requirements
Confidentiality considerations in the care of young adolescents, AAP News 2008;29;15: http://aapnews.aappublications.org/cgi/reprint/29/7/15.pdf
Palliative care is not the same as hospice care because it can begin when a patient is diagnosed or is undergoing treatment and may not indicate being near end of life. The hospice exclusion requires evidence that the member is receiving hospices services. Documentation that a member is in palliative care is not part of the exclusion.
Unlike UOP and COU, UOD requires the conversion of all dispensed opioids into morphine milligram equivalents (MME). The most current MME conversion file, published by the Centers for Disease Control and Prevention, removes buprenorphine, a partial opioid agonist, and states that the drug is not likely to be associated with overdose in the same dose-dependent manner as pure opioid agonists. NCQA removed it from the UOD measure in HEDIS 2019. This change aligns with the decision made by the Pharmacy Quality Alliance, the organization that developed the measure from which UOD was adapted for use in HEDIS.
No. Medical necessity review is not required for personal care services and other activities of daily living in UM 4–UM 7. However, if these services are covered benefits, any denial decision may be appealed and is included in the scope of appeal file review for UM 9.
No, but health literacy training programs are only a suggested approach for addressing communication needs and reducing barriers for patients and their families to access and understand health and safety information.
Yes, unhealthy behaviors can be the result of parent behavior but ultimately, we're looking for the unhealthy behaviors demonstrated by the patient (child). Secondhand smoke may be a direct example of a parent’s behavior affecting the child’s health and poor oral hygiene may be a child’s unhealthy behavior, but could result from lack of parental oversight or health literacy.
Practices need to identify behavioral health-related criteria pertinent to their specific patient population such as a behavioral health diagnosis, substance use, a positive screening result from a standardized behavioral health screen, or psychiatric hospitalizations. If the practice feels that patients with temper tantrums is an identifier for patients in need of care management, the practice can use that defining criteria.
