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.

Filter Results
  • Save
  • Email
  • Print
expand all

2.17.2015 Proportion of Days Covered by Medications (PDC) The DTX and PDC measures include a denominator exclusion for ESRD status. Does the status need to be “any time in the member's history,” or just during the measurement year?

Exclude members whose ESRD diagnosis is noted any time during the measurement year.

This applies to the following Programs and Years:
IHA P4P

2.15.2015 Use of credentialing and recredentialing verification to meet factor 3 For QI 12, Element A, factor 3, do verification activities conducted during the initial credentialing and recredentialing process count as quality measures?

CR 3–CR 6, credentialing verification activities do not count as quality measures for QI 12, Elements A and B. However, an organization may receive credit if its credentialing process incorporates clinical quality measures from NCQA (or other accreditors), the National Quality Forum (NQF), national medical boards (ABMS or AOA) or other quality measurement development sources. The organization may also incorporate member experience and cost-related measures into the credentialing process.

This applies to the following Programs and Years:

2.15.2015 Negative inferences of stating quality, experience or cost is not measured for practitioners and hospitials For QI 12, Element A, factor 3 and Element B, factor 2, did NCQA consider the negative inference of requiring an organization to state that it does not use quality, member experience or cost-related measures when selecting practitioners or hospitals to participate in its network?

Yes. The intent of this requirement is to provide consumers with quality information about Marketplace Silver Plans in order to help them make a better informed choice during enrollment. Therefore, organizations to be transparent about whether they used quality, member experience or cost-related measures when selecting practitioners or hospitals to participate in its networks.

This applies to the following Programs and Years:

2.15.2015 Meeting factor 3 for Marketplace POS products Our organization provides a point-of-service (POS) product, where members may access out-of-network services without requesting authorization or obtaining a referral. Are we required to meet QI 12, Element C, factor 3?

The intent of QI 12, Element C, factor 3 is that the organization collects data to understand how out-of-network services are used, whether or not members must make a formal request to use them. Therefore, NCQA considers “request for” and “use of” to be interchangeable terms. For POS products where members are not required to obtain authorization, the organization may use claims data, UM data (e.g., post-service request) or similar data.

This applies to the following Programs and Years:

2.15.2015 Meeting factor 3 for organizations with a single network for Marketplace and non-Marketplace product lines If an organization has a single network for Marketplace and non-Marketplace product lines and has a single practitioner directory that does not delineate practitioners by product line, for QI 12, Element A, factor 3, must the practitioner directory state that the organization does not use quality, member experience or cost-related measures when selecting practitioners?

Yes. QI 12, Element A applies even if all practitioners are available to all product lines. To receive credit, the organization’s directory must state that the organization does not use quality, member experience or cost-related measures when selecting practitioners to participate in its Marketplace Silver Plan.

This applies to the following Programs and Years:

2.15.2015 Meeting factor 3 for staff and group model health plans Does QI 12, Element A, factor 3 apply to organizations that contract exclusively with a staff model or group model as an identical network for all product lines?

No, factor 3 does not apply. Organizations must provide documentation that they contract only with these types of networks and do not limit access to any practitioners for the Marketplace Silver Plan.

This applies to the following Programs and Years:

2.15.2015 Web site linking requirement to meet factor 4 To meet RR 4, Element E, factor 4, are organizations required to link to specific hospital data or may they link to the general quality data landing page on a recognized source Web site?

The hospital directory must contain quality data from recognized national or state sources, or a link to recognized-source quality data specific to each hospital, if the link exists. If linking to the data is not technically possible (e.g., because of a requirement to accept terms of agreement), a link to the quality data landing page is acceptable. A link to the source’s general Web site home page does not meet the requirement.
 
 

This applies to the following Programs and Years:

2.15.2015 Meeting factor 3 if organization accepts “any willing provider” Our organization accepts “any willing provider” and does not use practitioner-selection criteria related to quality, member experience or cost-related measures. How can we receive credit for QI 12, Element A, factor 3?

To receive credit, the organization’s directory must state that the organization does not use quality, member experience or cost-related measures when selecting practitioners to participate in its Marketplace Silver Plan.

This applies to the following Programs and Years:

2.15.2015 Data that meets annual data collection and analysis requirements If an organization is surveyed less than a year after beginning operations, how does it meet elements that require annual data collection and analysis?

NCQA does not require the organization to collect and analyze a full year of data. For First Surveys, the look-back period is “at least once within the past year” for elements requiring annual data collection and analysis. The requirement is met if an organization collects and analyzes the data within a year of submitting the Survey Tool.

This applies to the following Programs and Years:

1.29.2015 Cervical Cancer Screening The P4P CCS testing measure specification states that there are no modifications from HEDIS, but the HEDIS CCS measure exclusion is optional and the P4P CCS measure exclusion is required. Should the P4P CCS exclusion be optional as well, to align with HEDIS?

No. The exclusion in the P4P CCS measure is required. The P4P CCS specification should list this change under Modifications From HEDIS.

This applies to the following Programs and Years:
IHA P4P

1.29.2015 Meaningful Use of Health IT Not all providers will have the required Medi-Cal population to attest to the State of California’s Meaningful Use incentive program. This change to the MUHIT domain may disqualify pediatricians who are meeting the Meaningful Use measures with the EHR. Might POs provide supplemental information for pediatricians who were unable to attest to Meaningful Use but are meeting Meaningful Use measure specifications?

In response to public comments received, the Technical Measurement Committee (TMC) considered that pediatricians who do not take Medi-Cal may not be eligible for incentive payments from the State of California or CMS. The TMC concluded that medical groups would have similar distributions of pediatricians.
We have received several questions about this policy; it is too late to change it for the MY 2014 measurement year, but staff will bring the issue to the committees again.  IHA’s mission is to promote quality improvement and affordability of health care for all Californians, including the 30% of Californians who are covered by Medi-Cal. As a result, staff feel that it is not unreasonable that pediatricians who do not see the required threshold of Medi-Cal patients will not qualify for the numerator in the MUHIT survey. Ultimately, a PO’s payor mix will have implications for performance measurement and payment- sometimes resulting in higher scores and payments, and other times not.

This applies to the following Programs and Years:
IHA P4P

1.29.2015 Meaningful Use of Health IT May providers who did not see patients during the measurement year be excluded from our NPI submission and e-measures provider denominator?

Physicians who are PCPs and who meet the criterion (MD or DO) in family/general practice, internal medicine or pediatrician/adolescent medicine should be included in submission, regardless of panel size. Providers who meet the criterion but are employed in an administrative-only role (e.g., medical director) may be excluded.

This applies to the following Programs and Years:
IHA P4P