FAQ Directory

As stated in the measure guidance section for the DMS and DRR measures, include encounters where a diagnosis of major depression or dysthymia was addressed. The intent is to use encounters that are associated with managing depression to identify members in the Initial Population and to identify encounters to be included in the denominator calculation for Rate 2. In the HEDIS 2017 October Update, the Depression Encounter Value Set was renamed Interactive Outpatient Encounter Value Set, to clarify that it identifies outpatient encounters that can take place in a variety of settings. These encounters must be associated with a diagnosis of major depression or dysthymia in order to meet the intent of the measures.

HEDIS 2017

For the 2016 standards year, NCQA evaluates and scores the UM 4, Element H file review as normal during the onsite survey.
The final score will be adjusted, after the onsite survey, to 100% if the organization includes all denials required by UM 4, Element H in the file review universe. 
If the organization does not include all denials in the file review universe, NCQA will adjust the organization's final score to 50% for the 2016 standards year and 0% thereafter.
 

UM-CR 2016

The updated Value Set Directory (VSD) is available to customers who purchased HEDIS 2017 Volume 2. Go to the NCQA Download Center to obtain the file: https://downloads.ncqa.org/customer/Login.aspx.
Note: The updated VSD is not labeled “10-3” in the Download Center. Click “Download” and the file name will include the date 10.03.16.

HEDIS 2017

The following types of denials are excluded from the file review for UM 4, Element H (UM 4F in UM-CR and MBHO):

• Denials based on medical necessity.
• Postservice payment disputes where the member is not at financial risk.
• Denials by the secondary insurance organization, based on coordination of benefits, when the member has not filed a claim with the primary insurance.
• Denials of vision, dental or alternative/complementary medicine services not included in the member’s medical benefits or included as a rider.
• Denials of duplicate claims, even if there are other reasons for the denial.
• Denials of claims for the following reasons:
  • A service included in a bundled or case rate that is incorrectly billed separately.
  • Incorrect or missing provider billing information (e.g., tax ID).
  • The member was not eligible on the date of service.
  • Nonexistent CPT or ICD code.

UM-CR 2016

No. Organizations may not use mass communication for this element. Organizations have three options to notify practitioners of the opportunity to discuss a denial:
1. In the denial notification (included in the denial file).
2. By telephone (time and date of the denial included in the denial file).
3. In materials sent to the treating practitioner, informing the practitioner of the opportunity to discuss a specific denial with a reviewer (evidence that the practitioner was notified that a physician or other reviewer is available to discuss the denial included in the denial file).
 

HP 2017

No. Because pharmacists do not treat patients, they are not considered same-or-similar specialists.

HP 2017

The following denials (rejections) are included in the scope of UM 4, Element H (UM 4, Element F in MBHO and UM-CR):

• Claims for prescriptions that were refilled too soon.
• Claims for prescriptions with the incorrect dosage or quantity.*
• Claims that were denied because the organization’s reasonable filing procedures were not followed (e.g., lack of prior authorization).

* Inaccurately filed claims that were rejected because of incorrect dosage or quantity may be considered pending until a decision is made. If the request is denied, the claim is included in the scope of UM 4, Element H.

HP 2016

The following types of denials are included in file review for UM 4, Element H (UM 4F in UM-CR and MBHO):

• Denials based on benefits that underwent a medical necessity review, which determined there was a benefit exclusion.
• Denials based on failure to follow the organization’s reasonable filing procedures. (i.e., lack of timely filing, lack of prior authorization).
• Auto-adjudicated claims denials or point of service (POS) claim denials that were not based on medical necessity (excluding duplicate claims).
• Denials not listed above that are not based on medical necessity, such as reversals or prior decisions due to fraud or improper billing.

UM-CR 2016

No. Facilities may not be mapped to a provider type unless an organization can demonstrate that all providers rendering services at the facility meet the NCQA provider definition defined in Appendix 3. Organizations should work with their HEDIS Compliance Auditor, who can review and approve mapping.

HEDIS 2017

No. To be considered a direct transfer, the admission date for the second stay must be on the same date of service or one day after the discharge date from the first stay.

HEDIS 2017

No. The inpatient stay must be on the same date of service or one day after the ED or observation visit date.

HEDIS 2017

No. A third paragraph should have been added that reads, “For factor 2, NCQA reviews a documented process, reports or materials, depending on the action taken to address identified opportunities.”
 
The update was intended to give organizations the option of presenting its updated policies and procedures, materials or a report showing revisions, if the intervention was revision of policies and procedures or materials.
 
NCQA will correct the scope of review for both elements in the November release of the NCQA Corrections, Clarifications and Policy Changes to the 2016 HP Standards.