FAQ Directory

No. Printed directories are not required for Elements A and B; however, if there is a printed directory, it must reference the quality information required by the elements.

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.

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.

HEDIS 2016

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).

HEDIS 2016

If any data is found in a supplemental data source, it is considered a supplemental data hit because the member would not be compliant for the measure/indicator without the data source.

HEDIS 2016

No. For HEDIS 2016 reporting, this new requirement was added to only the Effectiveness of Care (EOC) and EOC-like measures. “EOC-like measures” refers to the Utilization measures that have the same structure as and follow the same guidelines as the measures in the EOC domain (i.e., Frequency of Ongoing Prenatal Care, Well-Child Visits in the First 15 Months of Life, Well-Child visits in the Third, Fourth, Fifth and Sixth Years of Life, Adolescent Well-Care Visits). While supplemental data may be used for other measures, NCQA is not currently collecting this data element for other measures at this time.

HEDIS 2016

Customers can find additional information about these topics (including FAQs specific to this data source and the DMS measure) at the following link, http://ncqa.org/ECDS.

HEDIS 2016

Yes. Organizations with a Medicare product line can come through the NCQA Health Plan Accreditation process.

Unfortunately, the AMA has not released a CPT II code for a systolic reading of between 140 and 150 mmHg, or under 150 mmHg. We updated the CBPH measure to align with new blood pressure guidelines; if there are patients whose systolic reading falls between 140 and 150 and it is captured in other kinds of supplemental data, they can be included in the numerator. Our data suggests that use of CPT II codes to retrieve this data is uncommon. This data is available in EHRs as well as via supplemental sources such as registries and laboratory data. There is a note to this effect in the specification for the CBPH measure on page 50 of the manual (http://www.iha.org/pdfs_documents/p4p_california/MY-2014-VBP4P-Manual- 20141201.pdf).

This is similar to the way the HbA1C <8.0% is calculated, as there is not a CPT II code specific to <8.0%. More information can be found in the manual on page 66 (http://www.iha.org/pdfs_documents/p4p_california/MY-2014-VBP4P-Manual- 20141201.pdf).

IHA 2014

The organization must notify NCQA, in writing, within thirty (30) calendar days of the issuance of the notice of sanctions, issuance of a fine or issuance of a request for corrective action. 

The organization must also complete an annual attestation signed by an officer, or other authorized signatory of the organization, affirming that it has notified NCQA of all Reportable Events specified within the Agreement. NCQA-accredited health plans that reports HEDIS results include the attestation with its submission of the annual IDSS attestation submission for HEDIS® reporting.  Other health plans submit the completed attestation electronically to NCQA-Accreditation@ncqa.org. 

CM 2013

The organization must report the occurrence of any of the following actions by any federal or state regulatory authority:

• Issuance of Intermediate Sanctions and/or suspension of enrollment by CMS or any other federal or state regulatory authority.
• Issuance of any fine equal to or exceeding $50,000 related to Organization’s operations by CMS or any other federal or state regulatory authority.
• Issuance of any request for a corrective action by any federal or state regulatory authority where the substance of such corrective action relates to the Organization’s handling of utilization management decisions, network adequacy, benefit denials, complaints, grievances, appeals or other important patient safety matters. 

The above actions are referred to as the “final determination” within the Agreement.

CM 2010

Yes. The Agreement for Health Plan Accreditation Survey (the “Agreement”), specified in the “Organization’s obligations” section of the standards and guidelines, requires the organization to provide NCQA written notice within thirty (30) calendar days of the final determination by a state or federal agency with respect to request for corrective action, imposition of sanctions, changes in licensure or qualification status, if applicable, or violation of any federal or state law that affects the Scope of Review under the Standards and Guidelines. These are termed Reportable Events.

CM 2013