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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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 Should providers who were with our PO for less than three months of the measurement year be included in our NPI file submission?

Providers who were with a PO for less than six months of the measurement year may be excluded.

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

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

1.16.2015 Use of CAHPS for Experience Survey requirements Are there assessment of members' experience or satisfaction requirements where CAHPS cannot be used?

Yes. CAHPS 5.0H survey results may not be used for QI 6C: Annual Assessment of Behavioral Healthcare and Services, QI 7I: Experience with Case Management and QI 8I: Experience with Disease Management, where experience data must be limited to participants in the programs.  

This applies to the following Programs and Years:

1.15.2015 Applying First Survey requirements to organizations coming through WHP Certification for the first time If an organization is certified in HAs or Self-Management Tools under the HIP Standards and Guidelines and is coming through for certification under the WHP standards and guidelines, is it held to Renewal Survey requirements for WHP 3 and WHP 13 (new requirements for certified organizations)?

No. These organizations are held to Initial Survey requirements for the WHP 3 and WHP 13 standards.

This applies to the following Programs and Years:
WHP 2014

1.15.2015 Permitting practitioner’s review of UM denials with administrative licenses May practitioners with a current administrative license review denials of care based on medical necessity?

Yes. NCQA allows practitioners with a current administrative license to review denials of care based on medical necessity if the state issues administrative licenses that permit review of UM medical necessity cases.

This applies to the following Programs and Years:
UM-CR 2013

1.15.2015 Credentialing standards and unlicensed or uncertified practitioners for CR 1, Element A May organizations contract with and include unlicensed or uncertified practitioners, who are not within the scope of NCQA credentialing standards, in their networks?

The organization may contract with and include practitioners in its network who are outside the scope of NCQA credentialing standards, at its discretion. 

This applies to the following Programs and Years:

1.15.2015 Delegation oversight requirements if the previous delegation agreement was a draft If an organization’s draft delegation agreement was reviewed at the time of its Interim Survey, is the organization required to meet delegation oversight requirements if the delegation agreement is mutually agreed upon shortly before the organization submits its completed Survey Tool for its next survey?

If the delegate performed the activities prior to the agreement, the organization is expected to meet oversight requirements for the delegated activities during its next survey and associated elements are scored accordingly. Oversight relief and automatic credit rules apply if the delegate is NCQA Accredited or NCQA Certified.

This applies to the following Programs and Years:

12.22.2014 QRS and Commercial HEDIS Submission Should off-Marketplace enrollees in a QHP, be included in an organization’s NCQA HEDIS commercial submission?

For 2015, QHP enrollees as defined by CMS should not be included in an organization’s NCQA HEDIS commercial submission; they should only be included in the organization’s QRS submission. However, if an organization has already completed programming, NCQA understands that off-Marketplace enrollees in a QHP may have been excluded from the QRS submission. In these instances, these enrollees should be included in the organization’s NCQA HEDIS commercial submission.

With regard to requirements for reporting enrollee survey results and HEDIS measure results, NCQA plans to accept results that follow CMS reporting requirements. NCQA will review CMS beta-test results in fall 2015 before making final decisions on Accreditation reporting requirements for 2016.

For 2015, NCQA HEDIS commercial submissions (which may include off-Marketplace enrollees) will be used to score commercial health plan accreditation (HPA). HEDIS submissions are not required for Marketplace HPA scoring in 2015.
 

This applies to the following Programs and Years:
Exchange 2015

12.15.2014 CAHPS Health Plan Survey 5.0H, Child & Adult Version Has the CAHPS survey sample frame validation process changed?

Yes. Starting in reporting year 2015, NCQA requires that all Licensed Organizations apply a password lock to the validated and approved sample frame file used for conducting the commercial and Medicaid Child and Adult CAHPS and the Qualified Health Plan (QHP) Enrollee surveys. Survey vendors may not pull a sample from an unlocked file.

This applies to the following Programs and Years:
Exchange 2015|HEDIS 2015

12.11.2014 P4P Overview Page 7 of the P4P manual, states that quality preliminary reports are released on June 3, 2015 and the final date to submit an appeal is June 24, 2015. This does not match the dates on the quality timeline on pages 8-9.
The table on page 8 indicates that the PO Quality Preliminary Reports are posted on May 25, 2015. The first column of the table states that the Quality Results Questions and Appeals period have a June 16-24th timeframe, but the timeline in the second column says May 25- June 15th.
Please clarify the dates for the Quality Results Questions and Appeals period.

Thank you for pointing this out. The correct dates are as follows:
 
Page 7

  • Quality preliminary reports are released on May 25, 2015, and the final date to submit an appeal is June 15, 2015. IHA works with health plans and vendors to research and respond to PO questions about results provided in the PO Quality Preliminary Reports.

Page 8-9

Quality Results Questions and Appeals Period: IHA works with POs and Health Plans to address any data issues or questions related to quality results. Plans and POs may submit an appeal during this time.

  • May 25–May 29: POs submit initial questions to IHA.
  • May 30–June 5: IHA works with health plans and vendors to research and respond to PO questions.
  • June 6–15: Back-and-forth between POs, IHA and health plans to resolve questions or escalate to an appeal.
 May 25–June 15, 2015

 
The P4P staff will update this timeline and post to the IHA website alongside the December 1, 2014 release of the MY 2014 Value Based P4P Manual.
 

This applies to the following Programs and Years:
IHA P4P