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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NCQA does not specify file formats for exchanging clinical information, but strongly encourages adherence to Health Level Seven International (HL7) standards for clinical document exchange (e.g., QRDA, CCD) and electronic health care information exchange (e.g., FHIR).
Plans work with their NCQA-Certified auditor to complete the most appropriate section of the Roadmap for the data source. The eMeasure section is intended for use by data aggregators and EHR vendors, but may be adapted and modified. Plans should work with auditors or contact NCQA with specific questions about the eMeasure Roadmap or Audit Roadmap Section 5.
QI 4 requires organizations to collect data from all sources of member complaints and appeals. This includes UM coverage appeals addressed in UM 8-UM 9 and noncoverage appeals addressed in RR 2.
Note: Data collected and analyzed prior to December 15, 2017,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 prior to December 15, 2017, 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.
Yes. If the notification indicates that members may be represented by anyone, this is acceptable because the reference to “anyone” implies “including an attorney.” If the notification lists specific types of individuals, it must also specify “an attorney.”
Voicemail meets UM requirements only when the organization notifies a practitioner about the opportunity to discuss a denial decision. The organization must document who left the message, along with the date and time it was left. Voicemail messages do not meet any other notification requirement.
The time frame for completing the initial assessment begins when the member is determined to be eligible for complex case management. A member is eligible once identified using criteria from Element B, factor 2 and data sources in Element C (e.g., claims/encounter data, hospital discharge data). The initial assessment is not used to determine eligibility, although information gathered in the assessment may make a member ineligible.
Note: There is no “opt-in” option for identifying members.
No. Organizations may not use other data sources (e.g., supplemental or medical record data) when excluding members living long-term in an institution. The LTI flag in the Medicare Part C monthly membership file is the only source that may be used to identify this exclusion. NCQA was informed by CMS that all Medicare plans receive this file monthly and have access to this flag. NCQA plans to clarify this in the HEDIS 2018, Volume 2 Technical Update Memo, scheduled for release on October 2, 2017.
If the prescriber and/or pharmacy NPI is missing, count each dispensing event with a missing NPI as a different prescriber and/or different pharmacy when reporting the measure. NCQA plans to clarify this in the HEDIS 2018, Volume 2 Technical Update Memo, scheduled for release on October 2, 2017.
NCQA allows any individual at the organization to overturn a denial on appeal. Upheld denials still require same-or-similar specialist review for medical necessity decisions and review by a nonsubordinate for benefit decisions.
No. Presenting data alone is not sufficient. The case manager must draw a conclusion from the data and note it in the member’s file.
Note: Effective for complex case management files that were opened on or after September 1, 2017.
