FAQ Directory

No. An AOD diagnosis is required for the ED visit, but not for the inpatient stay.

This applies to the following Programs and Years:

Prior year’s validated historic hybrid medical record result files were removed from Section 5 (Supplemental Data) of the HEDIS Roadmap and are now listed as a data source used for reporting in Section 7 (Data Integration). Because of this change, these data should be loaded as administrative data, rather than as supplemental data, as in the past and should be considered administrative hits. This applies only to the previous year’s validated hybrid data, not to all medical record data or medical record data previously approved as supplemental data.

This applies to the following Programs and Years:

Yes. Replace the “ü” in the “Eligible Population” row with “Each of the 2 rates for each age stratification and total.” This is how the Eligible Population will be collected in IDSS.

This applies to the following Programs and Years:

NCQA has been monitoring ACIP’s review of the HPV vaccination schedule. Once the recommendation is published in CDC’s Morbidity and Mortality Weekly Report, the appropriate NCQA staff and panels will evaluate potential changes to the measure.
HEDIS 2017 evaluates performance for calendar year 2016; measure specifications for HEDIS 2017 are final. Proposed changes, if any, will be posted for Public Comment in February 2017 and, pending final approval by the NCQA Committee on Performance Measurement, will be included in HEDIS 2018.

This applies to the following Programs and Years:

Yes. For the Medicare product line, the organization may give the treating practitioner an opportunity to discuss a UM request with a physician or other appropriate reviewer prior to the decision. The denial file must contain documentation of this.

This applies to the following Programs and Years:

No. HEDIS for QRS requires collection of only Combination 2 and related antigens. IMA will not be scored this year.

This applies to the following Programs and Years:

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).
 

This applies to the following Programs and Years:

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

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.
 

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years: