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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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5.24.2018 CM 01D Is identifying a Medicare patient population considered a social determinant of health?

Although “older adult patients” is an acceptable criterion for social determinants, it should be based on patients’ access to care or needs due to their social situation (e.g., living alone, not being able to drive to an appointment, food insecurity). Because social aspects associated with age may not apply to all patients over 65, Medicare enrollment alone may not be the best indicator.
Remember that patients identified in CM 01 are those who may benefit from care management and for whom a care plan is expected in the criteria outlined in Competency B. If the population is large because it includes all Medicare patients, the practice may want to reexamine the criteria to ensure that appropriate patients are identified.
 

PCMH 2017

5.24.2018 CM 01E Does a patient referral for care management from an ED meet the requirements of this item within CM 01?

Yes. This factor requires a documented process for handling referrals made by outside organizations (e.g., insurers, health system, ACO, other providers), practice staff or patient/ family/caregiver for patients that might need additional care management support; an ED is an outside organization.
Note: A report or patient list of referrals is not required for this factor.
 

PCMH 2017

5.24.2018 CM 01D What are examples of social determinants of health?

Social determinants of health are conditions in the environment that affect a wide range of health, functioning and quality-of-life outcomes and risks and include:

  • Availability of resources to meet daily needs.
  • Access to educational, economic and job opportunities.
  • Public safety, social support.
  • Social norms and attitudes.
  • Exposure to crime, violence and social disorder.
  • Socioeconomic conditions.
  • Residential segregation.

Source: Healthy People 2020: http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health.
 

PCMH 2017

5.24.2018 CM 02 If a patient sample for the Record Review Workbook includes both pediatric and adult patients, do practices need to provide an example of each patient population for each criterion?

No. Practices with a patient sample that includes both pediatric and adult patients for reporting provide at least one pediatric example and at least one adult example for the criteria outlined in Competency B, but are not required to provide a pediatric example and an adult example for each criterion.

PCMH 2017

5.24.2018 CM 01C Does our practice meet the requirements if we use 65 years of age and older as the criterion for patients with poorly controlled or complex conditions?

No. Using only this age group does not meet the requirements. Identification of poorly controlled or complex patients can include older patients (e.g., >65 years) who also meet other high-risk criteria such as co-morbid conditions, frequent hospitalizations, mental health problems or frailty.

PCMH 2017

5.24.2018 CM 02 How do practices produce the report required for CM 02? How does it relate to CM 01?

CM 02 requires practices to create a process using criteria defined in CM 01 to identify patients for care management. The practice may use any method to identify these patients. For CM 02, practices need only provide a report showing the percentage of patients calculated from the number of patients identified using the defined criteria (numerator) in comparison to the entire patient population (denominator).
Note: Practices select at least three categories (CM 01) to define the subset of the patient population for care management for CM 02, and identify a population for care management (at least 30 patients) so they can report the criteria outlined in Competency B. Patients across the categories identified in CM 01 should be represented in the population identified for CM 02.
 

PCMH 2017

5.22.2018 AC 11 Urgent care visits or visits during extended hours may not be available with a patient’s primary care clinician. Does NCQA require a particular percentage of visits must be with a selected primary care clinician?

No. NCQA does not prescribe a percentage, nor does it expect patients to be seen by their selected primary care clinician for a specific percentage of visits.
 

PCMH 2017

5.22.2018 AC 12 Our practice offers night and weekend clinical advice coverage to patients through a phone service staffed by RNs. Does this meet the requirement for access to clinical advice?

Yes, if the phone service can provide after-hours access (AC 04) and can access the patient’s medical record either directly or through an available on-call provider with direct access (AC 12).
 

PCMH 2017

5.22.2018 AC 06 Our practice has a contract with a telehealth company that provides primary care to patients when they cannot come into the office. Does this meet the requirement for an alternative clinical encounter?

Yes, this meets the requirement if the telehealth provider is a clinician, provides a scheduled appointment and has access to practice systems and the patient’s medical record.

PCMH 2017

5.22.2018 AC 07 Does a link to the practice’s Web page showing available practice activities meet the requirements for AC 07?

Documentation may be a screen shot demonstrating system capability. This could be multiple screenshots (one of the Web portal page and screenshots for each item) or one screenshot showing evidence of multiple capabilities required (requesting medication refills, appointments and requesting a referral or test) on an active website. Practices are also encouraged to demonstrate these capabilities with their evaluator during their virtual check-in.

PCMH 2017

5.22.2018 AC 13 Is it mandatory to use the American College of Family Physicians mentioned in the guidance for determining panel sizes?

No. The ACFP tool is a helpful resource for practices to use when considering and managing panel sizes. If the practice prefers to use another method that is perfectly acceptable if it performs the same function.
 

PCMH 2017

5.22.2018 AC 02 Are practices required to provide a minimum number of same-day appointments?

NCQA does not specify a minimum number of same-day appointments per day for practices, and not all clinicians must offer same-day appointments.

PCMH 2017