FAQ Directory

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
 

This applies to the following Programs and Years:

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 
 

This applies to the following Programs and Years:

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

This applies to the following Programs and Years:

No, just having extra appointments based on the season would not meet the intent. The practice may have more same day appointments offered during these high-volume time periods but some same day appointments should be provided daily throughout the year.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

If the asthma action plan enables patients to track/monitor their progress and document health information at home using a form or some other method of documentation with helpful instructions for self-management, then it would be acceptable.

This applies to the following Programs and Years:

No. Although the immunizations are different formulations, Tdap and DTaP are integrally related. For this reason, NCQA considers them the same immunization for different age groups and does not accept them as two different immunizations.

This applies to the following Programs and Years:

Yes. Measures from the CHIPRA Initial Core Set meet the requirements.

This applies to the following Programs and Years: