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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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 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:

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:

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

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 What must POs report for e-measures, and how are these measures reported? Which providers should be included in reporting for the two e-measures?

The MUHIT domain comprises three rates, the first is the percent of providers who have attested to the national or state Meaningful Use EHR Incentive programs, and the second two are e-measures. To receive credit, POs must report:

  • A .csv file with a list of the PO’s providers’ national provider identifiers (NPIs). Instructions on file requirements were sent on January 7, 2015, and were discussed on the January 14–15 Webinars.
  • The two e-measures, Controlling High Blood Pressure and Screening for Clinical Depression and Follow-Up Plan.
    • For self-reporting POs, these measures are reported via the PO Clinical File Layout (http://iha.org/manuals_operations_2014.html). There is a separate file layout provided for non-self-reporting PO submission.
    • For each measure, two metrics are collected:
      • The percentage of providers who can report the e-measure.
      • The aggregated numerator and denominator, for providers who can report the e-measure.

To calculate, pull the numerators and denominators from the EHR systems of all providers who can report the measures; specifications are programmed in the certified EHR systems of providers who can report. Refer to pp 150–152 of the MY 2014 P4P Manual, released December 1, 2014.

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. As with the NPI file submission, POs have the option of excluding providers who were with the PO for less than six months of the measurement year. 

This applies to the following Programs and Years:
IHA P4P

1.29.2015 Childhood Immunization Status, 24 month Continuous Enrollment (CIS) The specifications for Childhood Immunization Status, 24-Month Continuous Enrollment list Combination 3 and Combination 7. The MY 2014 Measure Set document, posted on January 12, 2015, lists (http://iha.org/pdfs_documents/p4p_california/MY-2014-Measure-Set-20150112.pdf), only Combination 3. Which combinations should be reported?

Report only Combination 3. Combination 7 was listed in the manual in error and should not be reported. Per the MY 2014 Measure Set, only Combination 3 will be reported for this measure. The correction will be reflected in the PO and Health Plan Clinical Measure File. Note: Combination 3 and Combination 7 are reported for CIS, 12-Month Continuous Enrollment.

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