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.
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).
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.
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.
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/
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.
The pharmacy tables included in the MY 2015 Value Based P4P Manual should align with the pharmacy tables in HEDIS 2016 Volume 2.
General Guideline 32. Measures That Use Pharmacy Data states, “NCQA specifies a standardized list of medications known as the Nation Drug Code (NDC) list that applies to each pharmacy dependent measure. POs and health plans are required to use the list for applicable measures.” Find the NDC lists at: http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures/HEDIS2016/HEDIS2016NDCLicense/HEDIS2016FinalNDCLists.aspx
The table contains changes that should be reflected in the P4P drug tables.
| P4P Table Name | Drug Table Corrections |
| CDC-A, CBPH-A, and SPD-A: Prescriptions to Identify Members with Diabetes |
|
| Table SPC-B: High and Moderate-Intensity Statin Medications |
|
| Table SPD-B: High, Moderate and Low-Intensity Statin Prescriptions |
|
| Table OMW-A: Osteoporosis Therapies |
|
| Table CHL-A: Prescriptions to Identify Contraceptives |
|
| Table AMR-B: Asthma Controller and Reliever Medications |
|
| Table CWP-A and URI-A: Antibiotic Medications |
|
No. Because supplemental data may not be used to identify the eligible population, and the same events are used for the denominator and numerator in APC, supplemental data may not be used for this measure. The data elements table in Volume 2 for APC inadvertently includes the “Numerator events by supplemental data” data element. This field will not be included in the IDSS.
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.”
