FAQ Directory

Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can  ask a question through My NCQA.

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7.15.2015 MA Deeming and the Medicare product line NCQA recently released a memo informing interested parties that it no longer offers the MA Deeming program. Can organizations with a Medicare product line still come through NCQA Accreditation?

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

This applies to the following Programs and Years:

6.29.2015 Controlling Blood Pressure for People with Hypertension (CBPH) Why are there are no codes that encompass the 140-149 BP range that is new for senior hypertensive patients (BP control for members 60-85: <150/90 mm HG)?

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).

This applies to the following Programs and Years:
IHA P4P

5.01.2015 Notifying NCQA of Reportable Events How and when must the organization notify NCQA of Reportable Events?

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. 

This applies to the following Programs and Years:
CM 2014|WHP 2014|DM 2014|MHC 2010|CVO 2013

5.01.2015 Specific Regulatory Actions to be Reported What specific regulatory actions must be reported?

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.

This applies to the following Programs and Years:
CM 2014|WHP 2014|CVO DM|2014 MHC

5.01.2015 Reporting Regulatory Actions Are health plans required to report regulatory actions taken against the organization?

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.

This applies to the following Programs and Years:
CM 2014|WHP 2014|DM 2014|MHC 2010|CVO 2013

4.16.2015 Policy Clarification Support (PCS) Website URL Is there a new Web site URL for the PCS system?

Yes. The PCS system will be moved to a new Web site—http://my.ncqa.org—by the end of April. Customers who access the old PCS site will be automatically rerouted to the new site. The new site takes the same login and password; you will not need to change them.

This applies to the following Programs and Years:
HEDIS 2015

3.19.2015 Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Is QRS Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) collected using the hybrid method or the administrative method?

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life should be reported using only the administrative methodology as specified in the 2015 QRS Technical Specifications (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/2015-QRS-Measure-Technical-Specifications.pdf). Hybrid specifications are not available for this measure in the QRS.  The W34 measure is listed as a measure in the sample size table of the QRS Sampling Guidelines and was a misprint which will be corrected in the 2016 QRS Measure Technical Specification.
 
For organizations who have started medical record review for W34, please note, the IDSS will only accept the administrative elements of the measure for QRS.

This applies to the following Programs and Years:
Exchange 2015

3.15.2015 Chief nursing officer approves clean nurse-practitioner files May a chief nursing officer, who is a nurse practitioner, review and approve clean nurse-practitioner files in lieu of a medical director?

Yes. Nurse practitioners acting as chief nursing officers may approve clean files in states where nurse practitioners can practice independently, or independently with a collaborative physician arrangement.

This applies to the following Programs and Years:

3.15.2015 Eligibility for Automatic Credit Is an organization eligible for automatic credit if its accredited delegate has a single practitioner network with centralized credentialing (i.e., one credentialing committee; the same staff handle all practitioner credentialing) for all product/product lines, but is not accredited for the delegated product line?

Yes. Because the organization uses the same practitioner network for all product/product lines, and all practitioners are subject to CR file review during an NCQA Accreditation Survey, the file is eligible to receive automatic credit. This is an exception to the Product Match policy posted on Policy Updates page.

This applies to the following Programs and Years:

3.15.2015 HEDIS Reevaluation Does the new 2015 HPA annual HEDIS evaluation policy apply to organizations surveyed on or before June 30, 2015?

No. Organizations with submissions before July 1, 2015, are reevaluated on the HEDIS measures in effect at their last survey. Organizations submitting after June 30, 2015, are reevaluated on the HEDIS measures in effect for that reporting year.

This applies to the following Programs and Years:

3.13.2015 Meaningful Use of Health IT An FAQ about e-measure reporting posted on 1/29/15 states, “You should use the same definition of PCP as outlined in the NPI data file specification instructions. Providers in your denominator should include employed and contracted PCPs (MD or DO) in the following specialties: Family/General Practice, Internal Medicine and Pediatrician/Adolescent Medicine.”
The Controlling High Blood Pressure e-measure is specified for members 18 years and older, should pediatricians be excluded from the denominator?

POs have the option of excluding pediatricians from the Controlling High Blood Pressure e-measure denominator.

This applies to the following Programs and Years:
IHA P4P

3.13.2015 Proportion of Days Covered by Medications (PDC) An answer to an FAQ posted on 2/17/15 states, “Exclude members whose ESRD diagnosis is noted any time during the measurement year.”
The MARx System output, which contains the RxHCC codes, does not release the entire 2014 dates of service until after the IHA reporting deadline. Does the FAQ apply to both the RxHCC and ICD-9-CM code?

The intent is to use the most current information for the ESRD exclusion. If ICD-9-CM is used, then any code from the value set during the measurement year excludes the member from the denominator. If the MARx System output is used, then the most recent version applies. Although the time frames are not consistent between ICD-9-CM and RxHCC, it is the most current information to identify patients with ESRD. ICD-9-CM is preferred, but if it is not available, the most current MARx System output can be used.

This applies to the following Programs and Years:
IHA P4P