FAQ Directory

No. In such cases, NCQA expands the look-back period and reviews contracts executed any time prior to submission of the survey tool.

The notice does not have to include the posted information verbatim, but must include a description specific enough to give readers a clear idea of the topic and the general content, and must include a link to the information. The organization may group or summarize the information by theme.
EXAMPLES: 
For QI 2, Element B, the notification could state, “Information on our QI program description, including goals and achievements, is available on our Web site at [URL]…” For RR 3, Element A, the notification could state: “We have posted information on our Web site [URL] that will help you understand the benefits and services covered in your benefits plan; plan restrictions; how to obtain health care services and medications; how to file a claim for payment (if needed); how submit a complaint; how to appeal an adverse decision; and how [organization] evaluates new technology.”

Yes. According to the CMS HEDIS 2016 reporting requirements memo, MMPs are required to report all measures in Table 3. This includes COA, even though it is referenced as being SNP-only.

HEDIS 2016

No. The Marketplace product line is specifically for use with QRS reporting. There are differences between the HEDIS for the Quality Rating System and Volume 2 measure specifications. General Guideline 1 of the HEDIS for the Quality Rating System publication specifically states that QRS measure data must be collected separately for the Marketplace population. Future versions of the HEDIS for the Quality Rating System publication will only list the Marketplace product line. For those reporting on other product lines, the HEDIS Volume 2 publication must be used. 

Exchange 2016

Organizations seeking accreditation or certification in UM under the 2016 standards may receive automatic credit for updating delegation agreements prior to survey tool submission, to include:

• The new pharmacy requirements (UM 5, Elements E and F; UM 6, Element C; and UM 7, Elements G–I included in the 2016 Standards and Guidelines for the Accreditation of Health Plans) as delegated activities.
• The requirement for delegates to provide separate UM pharmacy files for review.

Updates may be made to the delegation agreement, to an addendum or in other binding communication between the organization and the delegate. 

UM-CR 2016

For 2016, NCQA will continue to score Marketplace product lines only on the Accreditation standards; however, whether an organization is currently accredited or plans to earn accreditation in 2016, NCQA will ascertain whether it continues to be a Qualified Health Plan under CMS requirements. If the organization is not listed on Healthcare.gov because it did not submit Quality Rating System (QRS) measures to CMS, its accreditation will be revoked. Prior to revocation, NCQA will discuss the issue with the organization. There may be circumstances where an organization is not required by CMS to report QRS measures. The organization would still be listed on Healthcare.gov and would be considered to meet NCQA requirements.
 
If your organization has any questions about this policy, please send them through the Policy Clarification System (PCS) at https://my.ncqa.org/ .

No. The WHP 2016 Reporting Tool audit designations will not be updated because the tool and specifications were released prior to these changes. Organizations should report WHP measures for 2016 using the existing WHP Reporting Tool. Any updates will be included in the 2017 WHP Reporting Tool, which will be released on March 31, 2016.

HEDIS 2016

No. Because CPT Category II codes and HCPCS are standard codes they are not eligible for mapping (the value sets include all standard codes that have been identified as appropriate for use in HEDIS reporting). The Category II and HCPCS codes included in PQRS measures were created specifically for use in PQRS reporting and are not appropriate for use in reporting HEDIS measures. If a service or procedure was rendered by a provider, the expectation is that the provider will submit a claim to the health plan for the service or procedure; the codes expected to be on the claim are included in the HEDIS value sets and identify the member for the HEDIS measure.

HEDIS 2016

Yes. The W15 measure does not have exclusions and this data element was included in error. It will be deleted in future publications.

Exchange 2016

Yes. The following changes were made and were not listed in the Summary of Changes spreadsheets.

• In the Acute Conditions value set, diagnosis codes that starts with a V were mislabeled “ICD9PCS.” The label was changed to “ICD9CM.”
• In the Potentially Planned Procedures value set, the ICD9 procedure codes were mislabeled “ICD9CM.” The label was changed to “ICD9PCS.”

IHA 2015

No. Due to the addition of the Medicare product line to the RAS measure, this measure will not be publicly reported for the Medicare product line for HEDIS 2016. The commercial and Medicaid product lines for RAS will continue to be publicly reported for HEDIS 2016.

HEDIS 2016

For administrative-only measures, information abstracted from the medical record is considered nonstandard supplemental data and is subject to all requirements described in General Guideline 34. The supplemental data must include all data elements required by the measure specification. For pharmacy data, this means that all data elements from the NDC lists must be present: the generic name, strength/dose, route and date when the medication was dispensed to the member. Generic documentation in the medical record (e.g., that a patient “was prescribed” or “is taking” a medication) that does not include drug name, strength/dose and dispense date does not meet criteria.

HEDIS 2016