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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5.20.2016 UM 4, Element H File Review and Medical Necessity Denials Are medical necessity denials included in the UM 4, Element H file review?

No. If an organization inadvertently includes a medical necessity denial in the UM 4H benefit denial file review, NCQA verifies that the file is appropriately classified as a medical necessity denial. If so, NCQA scores the file NA. If not, NCQA reviews the files under the benefit denial requirements of UM 4H.
 

UM-CR 2016

5.20.2016 UM 4, Element H File Review Does UM 4, Element H file review include benefit denials that resulted from the UM medical necessity review process?

Yes. If an organization inadvertently includes a benefit denial in the UM 4–UM 7 medical necessity denial file reviews, NCQA verifies that the file is appropriately classified as a benefit denial. If so, NCQA scores the file NA. If not, NCQA reviews the files under the medical necessity denial requirements of UM 4–UM 7.

UM-CR 2016

4.15.2016 Product line requirement for QI 4, Element E What evidence must organizations present to meet QI 4E?

For factor 1, organizations present a report of complaints and appeals by product line.
For factor 2, organizations present a report showing member experience results by product line. Organizations are not required to conduct a separate survey for each product line brought forward. If organizations conduct one behavioral healthcare survey across all product lines, results must be presented by product line, even if response rates are low.

4.15.2016 Organization-level timeliness reports Is a corporate level report acceptable for UM 5, Element G?

No. Reports on timeliness of UM decision making may not be at the corporate level. Reports must be at the accreditable-entity level.

4.15.2016 Exchange Benchmarking Data We are looking for external benchmarks for Exchange results. When will they be available?

NCQA collects clinical data for the Quality Rating System (QRS) under contract for CMS, but does not collect or report Exchange data for any other purpose.

Published CMS guidance (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/2019-QRS-and-QHP-Enrollee-Survey-Technical-Guidance_FINAL_20181016_508.pdf) states (page 19, Section 8, Quality Rating Information Preview Process), “The proof sheets will include benchmark information for measure results and an associated definition/rationale for any invalid/non-numeric results (e.g., NR).”

You can e-mail the Exchange Operations Support Center Help Desk at CMS_FEPS@cms.hhs.gov or phone 855-267-1515 if you have questions about benchmarks for Exchange QRS data. Reference “Exhange Quality Initiatives (MQI)-QRS” in the subject line.

Exchange 2016

4.15.2016 Off-label medication use denials in UM 4H Are denials for “off-label” medication use included in the file review for UM 4, Element H (UM 4F in UM-CR and MBHO)?

Yes. Denials for off-label medication use are included in the scope of UM 4, Element H (UM 4F in UM-CR and MBHO) if the organization covers medications only for “on-label” use.

UM-CR 2016

4.15.2016 State restrictions on information provided to prospective members and RR 5 If an organization can provide only certain information to prospective members, due to regulatory restrictions, and that information does not cover some requirements in RR 5, how does NCQA score the unmet requirements?

NCQA holds the organization harmless (scores the impacted requirement NA) if restrictions prevent it from meeting NCQA requirements. The organization must provide documentation of the regulatory restriction.

4.15.2016 Experimental/investigational procedure denials in UM 4H Are denials of requests for experimental or investigational procedures included in the file review for UM 4, Element H (UM 4F in UM-CR and MBHO)?

Yes. If an experimental or investigational procedure is explicitly excluded from the benefits or medical policy, this is a benefit denial and is included in the scope of UM 4, Element H (UM 4F in UM-CR and MBHO).

UM-CR 2016

3.25.2016 P4P Overview In the MY 2015 Value Based P4P manual Humana is included in the list of plans participating in Medicare Advantage measurement and reporting, but is not included in the clinical data file layouts. Is Humana participating in P4P Medicare reporting, and should POs be including Humana members in their self-reported rates?

No, Humana will not be participating in P4P Medicare Advantage measurement and reporting, and should not be included in PO data reporting. Self-reporting POs and health plan clinical data file layouts did not include Humana and Humana members should not be included in self-reporting PO or health plan rates.

IHA 2015

3.15.2016 Review process versus review outcome Does the type of review (i.e., medical necessity, benefit or other) determine if a denial is included in the file-review universe for UM 4, Element H (UM 4F in UM-CR and MBHO)?

No. The outcome (reason for the denial) determines which files are included. If the decision is not made on the basis of medical necessity, but on the basis of a benefit or an administrative limitation, the file is included in the scope of UM 4, Element H (UM 4F in UM-CR and MBHO).

UM-CR 2016

3.15.2016 Types of files included in the UM 4–UM 7 file-review universe (excluding UM 4H) Are denials based on benefits (whether or not they underwent a medical necessity review) included in the file review universe for UM 4, Elements C–E, UM 5 Elements A-F, UM 6 and
UM 7?

No. Only denials based on medical necessity are included in the scope of review for UM 4, Elements C–E, UM 5 Elements A-F, UM 6 and 
UM 7.

3.15.2016 Expected Counts in IDSS for IHU, EDU and HPC How should the Expected counts be reported in IDSS for Inpatient Hospital Utilization, Emergency Department Utilization and Hospitalization for Potentially Preventable Complications? Do they need to be rounded?

The Expected counts, discharges or visits depending on the measure, must be rounded to four decimal places using the .5 rule when reporting the final values in the IDSS.

HEDIS 2016