The organization may submit one analysis report for all its product lines, including Marketplace, but the analysis for the Marketplace line must be separate in order to receive credit for QI 12, Element C.
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10.15.2015 Complaints and Appeals Analysis for Marketplace product line May an organization submit one report for all its product lines, including its Marketplace product line?
10.15.2015 Technical Update In the Technical Update memo, the following language was added to Persistence of Beta-Blocker Treatment After a Heart Attack and Follow-Up After Hospitalization for Mental Illness: “Use only facility claims to identify discharges and diagnoses for denominator events (including readmissions or direct transfers). Do not use professional claims.” For other measures that use the same method and value sets to identify a discharge (or an admission), should the organization use both facility and professional claims?
10.15.2015 Childhood Immunization Status When abstracting medical record data for the hepatitis B vaccine, must the rules for the newborn hepatitis B vaccination in the administrative specification be followed?
When abstracting hepatitis B vaccine data from the medical record, there is no requirement that one be a “newborn” vaccine specifically, and there are no date restrictions. For hybrid reporting, when all events come from the medical record, documentation of three hepatitis B vaccines administered on three different dates of service meets criteria.
The newborn hepatitis B vaccine instructions and value set are intended to be used only for administrative data. The rules for the newborn hepatitis B vaccine are in place because the code in the Newborn Hepatitis B Vaccine Administered Value Set is a generic code that indicates a vaccine was administered but it does not indicate which vaccine was administered (it is not specific to hepatitis B). If this code occurs during the eight-day period (date of birth plus 7 days) then it is appropriate to assume it was a hepatitis B vaccine that was administered (since this is the only vaccine that is routinely administered to all children before discharge from the hospital).
This applies to the following Programs and Years:
HEDIS 20169.30.2015 QRS and Off-Market Commercial HEDIS Submission Should Off-Marketplace plans include their membership in QRS and in Marketplace accreditation?
9.15.2015 Documentation requirements for file review when delegating to a certified CVO What documentation must an NCQA-Certified CVO provide to an organization for an accreditation survey file review?
The organization and the CVO determine the documentation methods for reporting information. Acceptable methods include a checklist, the actual documents and access to electronic credentialing files. When an organization delegates to a certified CVO, NCQA reviews the organization’s credentialing files to assess timeliness and ascertain whether the credentialing decision was made within the specified time limits (i.e., 180 calendar days from verification).
This applies to the following Programs and Years:
CVO 20139.15.2015 Specificity of the Vendor Acknowledgment If an organization contracts with a vendor to meet NCQA requirements (e.g., MEM 1, MEM 2), how specific does the written vendor acknowledgment have to be?
If the vendor performs all functions (i.e., MEM 1: Health Appraisals), the written acknowledgment must state that the vendor performs all functions. If the vendor does not perform all functions, the acknowledgment must explicitly state the responsibilities of the vendor and those retained by the organization.
This applies to the following Programs and Years:
9.15.2015 Acceptable Documents for Policies and Procedures Many scopes of review in the standards require policies and procedures. How does NCQA define “policies and procedures” and what are acceptable documents?
Policies and procedures are official documents that describe business rules and a course of actions, and the methods for carrying out the actions. Simply put, policies and procedures specify how an organization performs the requirement under review—the organization’s “documented process.”
Usually, NCQA expects the organization to present only the components of the policies and procedures that demonstrate it meets the requirement. Depending on the element, this may include, but is not limited to, a program description, operating guidelines or process flowchart.
This applies to the following Programs and Years:
HIP 2014|WHP Cert|2016 DM|2014 UM-CR8.15.2015 Automatic credit for file review elements delegated to an NCQA-Accredited/Certified entity How is an organization scored for file review elements if the delegation agreement is signed just before survey submission?
The organization receives automatic credit for files selected from the NCQA Accredited/Certified delegate if the agreement is signed before survey submission and if all automatic credit requirements are met, as described in the delegation appendix, unless delegation is with an NCQA-Certified CVO. In that case, the organization receives automatic credit for verification, but files are reviewed for timeliness.
This applies to the following Programs and Years:
8.15.2015 Printed directory requirement in QI 12 Are printed directories required for QI 12, Elements A and B?
8.14.2015 General Guidelines Are members with a hospice benefit excluded from Medicare HEDIS reporting?
Yes. For Medicare reporting, exclude members who elect to use the hospice benefit (i.e., use hospice service) any time during the measurement year. These members must be removed prior to determining the measure’s eligible population and drawing the sample for hybrid measures.
This applies to the following Programs and Years:
HEDIS 20168.14.2015 General Guidelines Given the addition of the “Numerator events by supplemental data” data element, how will the reported rate be calculated?
The reported rate calculation is the sum of all numerator events by administrative data, medical record data and supplemental data, divided by the eligible population for administrative measures, or by the denominator for hybrid measures (i.e., reported rate = numerator events by administrative data + numerator events by medical record data + numerator events by supplemental data / eligible population or denominator).