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).
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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)?
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.
This applies to the following Programs and Years:
IHA P4P3.15.2016 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).
This applies to the following Programs and Years:
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?
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?
3.15.2016 Classification of pharmaceutical requests at the point of service How should organizations classify requests for medications dispensed at the point of service?
2.24.2016 Digital Mammography for Breast Cancer Screening Is digital mammography included in the HEDIS® Breast Cancer Screening Measure?
The HEDIS® 2016 Breast Cancer Screening (BCS) measure aligns with the 2009 US Preventive Services Task Force (USPSTF) guidelines. The guideline concluded the evidence was insufficient to assess the additional benefits and harms of digital mammography instead of film mammography for breast cancer screening. NCQA understands mammography practice, coding and technology have evolved over time to include digital mammography, and the current HEDIS measure includes CPT codes that represent either traditional mammography or digital mammography and cannot be delineated through administrative reporting. However, three HCPCS G codes, specific to digital mammography, were inadvertently included in the Mammography Value Set. Because the HEDIS 2016 specifications are frozen, NCQA will allow plans to follow the current measure specification and associated value sets as written.
The measure will be evaluated for HEDIS 2017 and the value-sets will be updated accordingly based on newly released USPSTF Guideline recommendations.
This applies to the following Programs and Years:
HEDIS 20162.19.2016 P4P Value Set Directory The Ambulatory Surgery Option A and Laboratory and Pathology Services value sets each contain 8 codes that begin with “X” (e.g., X1020913) and are labeled as CPT codes. Are these valid codes, and should they be used for P4P reporting?
No. The CPT codes that begin with “X” are not valid and are not required for use in P4P reporting. Organizations can exclude these codes from the value set. If these codes were included in P4P programming, it is expected that there will be no impact; the codes are not valid and will not occur in claims data.
This applies to the following Programs and Years:
IHA P4P2.05.2016 Meaningful Use of Health IT: CMS EHR Incentive Program May we exclude from our NPI list and e-Measure submission, providers with a hardship exception from CMS for the EHR Incentive Program?
1.27.2016 Meaningful Use of Health IT: e-Measures For the e-Measure portion of the MUHIT domain, POs are scored only on the “percentage of providers who can report the e-Measure.” Do we need to report both metrics for each e-Measure, or just the first rate?
1.27.2016 Proportion of Days Covered by Medications (PDC) In the December 1, 2015, version of the PQA NDC list (03_MY_2015_NDC_List_for_PQA-developed_measures_2015-12-01.xls), the columns for “Repaglinide_Flag” and “Canagliflozin_Flag” in the “Diabetes” tab are whited out. Should these columns be included?
Yes. The columns “Repaglinide_Flag” and “Canagliflozin_Flag” should be included in the December 1, 2015, version of the PQA NDC list. Even though these columns are not shaded and the name of the medication does not appear at the top, the “x” flags appear in the spreadsheet.
An updated version of the PQA NDC list (03_MY_2015_NDC_List_for_PQA-developed_measures_2016-1-26.xls) is available from NCQA at: http://store.ncqa.org/index.php/catalog/product/view/id/2223/s/my-2015-p4p-manual-and-value-set-directories/
This applies to the following Programs and Years:
IHA P4P1.27.2016 Cervical Cancer Overscreening (CCO) For step 2 of the numerator, is the 30–64 age criterion only based on cervical cytology with an HPV co-test? Does cervical cytology between April 1, 2013, and December 31, 2015, and cervical cytology and an HPV co-test between April 1, 2011, and December 31, 2012, meet the numerator criterion for step 2?
No. The measure requires each rate to be reported separately and as a total rate. This example does not meet the numerator criterion because it ONLY looks at women 30–64 with more than one co-test, which is a combination of a cervical cytology screening AND an HPV test. Only women who had a combination of both tests more than once are included in the numerator.
Note: Current cervical cancer screening guidelines for average-risk women do not state that women 30–65 years of age with a “cervical cytology” in 3 years and a “cervical cytology and HPV co-test” in 5 years are considered overscreened. For P4P reporting, we look only at cases of overscreening as explicitly outlined by the guidelines. P4P staff and committees will continue to review clinical practices and cervical cancer screening guidelines.