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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11.15.2017 Reporting Requirements The HEDIS 2018 Volume 2 Technical Update memo announced the retirement of “Annual Monitoring for Patients on Persistent Medications (MPM)” for Medicare and the name change from “Inpatient Hospital Utilization (IHU)” to “Acute Hospital Utilization (AHU).” This caused a discrepancy between the CMS Reporting Memo and HEDIS 2018 Volume 2 Technical Specifications. Will CMS release a clarification on what must be reported for HEDIS 2018 for Medicare?

Yes. CMS released a clarification on October 11, 2017, through HPMS, announcing that MPM was retired and is not required for HEDIS 2018 reporting; it also clarified that “Inpatient Hospital Utilization” is now “Acute Hospital Utilization” and should be reported as the updated measure. If you have additional questions, contact CMS at HEDISquestions@cms.hhs.gov.

This applies to the following Programs and Years:
HEDIS 2018

11.15.2017 Use of Opioids at High Dosage In the HEDIS 2018 Volume 2 Technical Update memo Table UOD-A includes a variable ranging from 4-12 for the MED Conversion Factor for methadone based on mg/day of methadone used. However, in the HEDIS 2018 NDC MLD Directory all NDCs for Methadone under the medication list "Opioid Medication" have a MED Conversion Factor (column M) of 3. For performing the MED calculation in UOD, which MED Conversion Factor should be used for methadone?

For HEDIS 2018 reporting, for methadone, the MED conversion factor of "3" should be used as listed in the NDC list; not the factors listed in Table UOD-A. We will reevaluate using the sliding scale conversion factors for HEDIS 2019.

This applies to the following Programs and Years:
HEDIS 2018

11.15.2017 General Guidelines General Guideline 17 says that "Members with dual commercial and Medicaid coverage must be reported in the commercial HEDIS reports. These members may be excluded from the Medicaid HEDIS reports." If a member has primary insurance in a Medicaid plan and secondary insurance in another Medicaid plan at any time during the measurement year, should the secondary Medicaid plan report the member in their HEDIS report?

To meet criteria for dual coverage, the member should have dual coverage at the end of the continuous enrollment period (dual coverage is assessed on a measure-by-measure basis). For example, if a measure's continuous enrollment period ends on December 31 of the MY and has dual Medicaid and commercial enrollment on that date, then the member may be excluded from the Medicaid HEDIS reports for the measure and only be reported in the commercial product line (General Guideline 23 in HEDIS 2018 Volume 2). In cases where the member is dually enrolled in two Medicaid plans, the secondary Medicaid payer would have the choice to exclude the member if the primary Medicaid coverage was offered through a different organization.

This applies to the following Programs and Years:
HEDIS 2018

11.15.2017 The Value-based Payment worksheet What is the Value-Based Payment worksheet for PHM 3B, and where can we find it?

The Value-Based Payment worksheet gives instructions on required reporting to satisfy element PHM 3B: Value-Based Payment Arrangements. It is a workbook that must be completed as part of the survey tool.

This applies to the following Programs and Years:
HP 2018

11.15.2017 Delegation of NET Directories How is NET 7, Element E, factor 1 scored when an organization delegates only the directory functions in NET 6?

The organization is scored NA for factor 1 because the physician and hospital directories do not involve network management procedures.
 

This applies to the following Programs and Years:
HP 2017, 2018

11.15.2017 Updated: Timeliness of postservice appeal decisions for Medicare and Medicaid Does the recent change for Medicare and Medicaid postservice appeals from 60 calendar days to 30 calendar days align with Chapter 13 of the Medicare Managed Care Manual?

No. Medicare product lines continue to follow the 60-calendar-day time frame for postservice appeals.

Note: The requirement is correct for Medicare product lines; Medicaid product lines continue to follow the 30-calendar-day time frame for postservice appeals.

This applies to the following Programs and Years:
HP 2018|UM-CR-PN 2018

11.15.2017 Transitions of Care The HEDIS 2018 Volume 2 Technical Update memo indicates the following change in the Transitions of Care specifications: In the first sentence of the third paragraph, replace “date/time” with “date.”
Should this change also apply to the first bullet in the “Note” section of the technical specifications that reads, “The following notations or examples of documentation do not count as numerator compliant:
*Documentation of notification that does not include a time frame or date/time stamp.”

Yes. Replace the reference to “date/time” in the first bullet in the Note section with “date.”

This applies to the following Programs and Years:
HEDIS 2018

11.15.2017 Guidelines for Calculations and Sampling The footnote on page 45 of HEDIS 2018 Volume 2 indicates that the lowest Prior Year rate from “Prenatal and Postpartum Care” and “Frequency of Prenatal Care” should be used to reduce the sample size for PPC. Given that FPC was retired with the HEDIS 2018 Volume 2 Technical Update, should the PPC MRSS use the lower rate of the Postpartum and Prenatal care indicators?

Yes. With the retirement of the FPC measure, organizations may reduce the sample size for the PPC measure using the lowest rate of the 2 indicators from the current year’s administrative rate or the prior year’s audited, product line-specific rate.

This applies to the following Programs and Years:
HEDIS 2018

11.09.2017 Additional Resources Are there any outside resources that may help me in the PCMH transformation process?

Content Area Criteria Resource Link Description
TC 02 http://www.ihi.org/resources/Pages/Changes/OptimizetheCareTeam.aspx Resource on how to optimize staff responsibilities
  02 https://www.integration.samhsa.gov/operations-administration/OATI_Tool3_ART.pdf Toolkit on how to optimize administrative staff responsibilities to benefit clinical practice
  02 http://www.improvingprimarycare.org/team/pcp Resource on how to optimize staff responsibilities
  04 https://www.stepsforward.org/modules/pfac Module teaching how to create a patient advisory council
  07 http://www.nachc.org/research-and-data/prapare/toolkit/ Toolkit to better understand social determinants of health
  08 https://integrationacademy.ahrq.gov/sites/default/files/AHRQ_AcademyGuidebook.pdf Information on behavioral healthcare integration in primary practice
KM 02 G https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/ Social needs screening toolkit
  12 https://www.cdc.gov/media/releases/2012/p0614_preventive_health.html Discussion on benefits of preventative care
  14 https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/match/match.pdf Guide to medication reconciliation at transitions
  16 http://www.teachbacktraining.org/ Information on teach back training
  17 http://www.improvingprimarycare.org/work/medication-management Guide to medication management
  24 https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html Toolkit for shared decision making
  24 http://msdmc.org/3-assess/ Toolkit for shared decision making
  24 https://shareddecisions.mayoclinic.org/ Informative website about shared decision making
  13 http://www.jabfm.org/content/28/2/170.full.pdf   "Patient Empanelment: The Importance of Understanding Who Is at Home in a Medical Home"
AC 13 http://www.annfammed.org/content/10/5/396.full  "Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation"
    http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/aug/1764_hong_caring_for_high_need_high_cost_patients_ccm_ib.pdf Article discussing benefits and strategies to care management
CM 03 https://nf.aafp.org/Shop/practice-transformation/risk-stratified-care-mgmt-rubric Risk stratification rubric available to members of the AAFP
  03 http://www.calquality.org/storage/documents/cqc_complexcaremanagement_toolkit_final.pdf Risk stratification rubric from California Quality Collaborative
  03 http://www.millimanriskadjustment.com/ MARA  – The Milliman Advanced Risk Adjuster is a model of risk stratification in which risk scores are normalized to a given population.
  04 http://www.aafp.org/fpm/2015/0100/fpm20150100p7-rt1.pdf Care Plan template from AAFP, not exclusive to members
  06 http://www.dartmouthatlas.org/downloads/reports/preference_sensitive.pdf Resource on how to incorporate patient preference into care management
  08 http://www.ihi.org/resources/pages/tools/selfmanagementtoolkitforclinicians.aspx Toolkit to aid clinicians in promoting self-management
  08 https://www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/index.html Resources on self management
  08 http://champsonline.org/tools-products/clinical-resources/patient-education-tools/patient-self-management-tools Condition specific self management tools
  08 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/ Article discussing proper communication between primary and specialist clinicians
CC 14 http://nihcr.org/analysis/improving-care-delivery/prevention-improving-health/ed-coordination/ Information on improving communication between emergency and primary physicians
  16 https://share.kaiserpermanente.org/article/kaiser-permanente-study-finds-tailored-post-hospital-visits-lower-risk-readmission-medicare-advantage-patients/ Article discussing advantages of post hospital primary care visits
QI   https://www.ahrq.gov/sites/default/files/publications/files/pcmhqi2.pdf Resource for building quality improvement in primary care
  03 http://www.ihi.org/resources/Pages/Measures/ThirdNextAvailableAppointment.aspx Information on how to utlize third next available appointment measurement
  08 https://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod4.html Benefits of PDSA cycle

This applies to the following Programs and Years:
PCMH 2017

10.15.2017 ECDS What happens if members seek services from a provider who cannot share health care data using ECDS?

10.15.2017 ECDS May we use claims for ECDS reporting?

Administrative claims are considered an ECDS data source if the payment system is automated and data are accessible by the practitioner/practitioner group that is accountable for clinical services provided to plan members (e.g., if claims are used to identify an inpatient stay, the primary care provider must be able to access the details of the stay). Report all measure results identified by claims in the “Administrative claims” source system of record (SSoR) category.

This applies to the following Programs and Years:
HEDIS 2018

10.15.2017 ECDS Are all data used to determine member compliance with the denominator, numerator or exclusion required to come from an ECDS, or may data from multiple sources be used?

ECDS reporting encourages use of multiple data sources to provide a complete and accurate picture of the health care experience. Transactional and clinical data from several sources may be used for ECDS reporting if data meet eligibility criteria. Click here for information on allowable data sources: http://www.ncqa.org/HEDISQualityMeasurement/ECDS/AllowableData.aspx

This applies to the following Programs and Years:
HEDIS 2018