FAQ Directory

For Marketplace (Exchange) products, HEDIS will follow the federal Marketplace Quality Rating System (QRS). CMS will release QRS measure specifications and reporting guidelines (including HEDIS) in September 2014.

Exchange 2015

Yes, if the flat copay amount is specified on the organization’s Web site. Members must have no additional financial liability (i.e. co-insurance, deductibles, charges in excess of allowed amounts, differentials in cost between in-network care and out-of-network care, costs that vary for the formulary) for services and cannot be balance-billed by a practitioner, provider or other party.

This exception does not apply to Element B in MEM 3 and 5.

Yes. The 45-calendar day notice period for providing results and providing an opportunity for a physician to request a correction or change applies to each cycle of measurement and action an organization takes, regardless of frequency (e.g., biannual, annual, semiannual, quarterly); however, if an organization recalculates results without changing its methodology or measures, it does not need to provide the methodology again as long as it supplies information on how to obtain that methodology.

The exception to the minimum 45-calendar-day notice period for action is when the action involves only pay-for-performance activities that are not publicly reported (e.g., an action that is only between the organization and the physician). In this instance, the organization may provide the results and methodology concurrent with additional or bonus payment. It must still provide a process for the physician to request corrections or changes.

No. Because of the delay in ICD-10 implementation, ICD-10 codes will not be used during the HEDIS 2015 measurement year (the 2014 calendar year) and therefore will not be included in the HEDIS 2015 Value Set Directory.

Purchasers of HEDIS 2015 technical specifications will receive a separate file with ICD-10 codes proposed for inclusion in future releases of HEDIS, but the codes will not be considered part of the 2015 measure specifications.

HEDIS 2014

The December 2, 2013, release of the MY2013 P4P Value Set Directory (VSD) was incomplete for two value sets used to report the Encounter Rate by Service Type (ENRST) measure. Therefore, we are releasing a 2014-03-19 version of the VSD that contains the following changes:
· Laboratory and Pathology Services Value Set: Added 1331 CPT codes
· Radiology and Imaging Services Value Set: Added 21 CPT codes

The added codes can be identified in the VSD as follows:
· In the P4P Value Sets to Codes spreadsheet, set the filter in column C (Value Set Version) to “2014-03-19” to identify added codes.
· In the P4P Summary of Changes spreadsheet, set the filter in column F (Revised) to “2014-03-19” to identify added codes.

To access the correct value sets, go to the download center at https://downloads.ncqa.org/customer/Login.aspx and log in.

If you have any questions, contact p4p@ncqa.org.

IHA 2013

Yes. If the organization does not contract with practitioners directly, it may rely on a contracted entity (e.g., rental network, physician organization, medical group) to distribute information to practitioners.

Thank you for bringing this to our attention. Unfortunately, the age breakdown in the brackets are historical, and the new guidelines that came out last year do not sync easily with them. For MY 2014, we can consider eliminating the age breakouts and simply collecting the overall versions of these measures.

Unfortunately, it is too late to change the file layout at this point because plans and POs are in the midst of programming. For MY 2013, women who are 30 should be included in the “Too Frequently No Hyst: Ages 24-30” row; women who are 31-65 should be included in the “Too Frequently No Hyst: Ages 31-65” row.

IHA 2013

Thank you for bringing this to our attention. When converting coding table references to value set references, the Option A UBTOB language and Option B POS language was inadvertently omitted. For OSU, Options A and B should include both POS and UB Type of Bill codes and should read as follows:

Any of the following code options meet criteria:

· Option A: Ambulatory Surgery Option A Value Set with Ambulatory Surgery POS Value Set .

· Option A: Ambulatory Surgery Option A Value Set with Ambulatory Surgery UBTOB Value Set.

· Option B: Ambulatory Surgery Procedure Value Set with Ambulatory Surgery UBREV Value Set and Ambulatory Surgery UBTOB Value Set.

· Option B: Ambulatory Surgery Procedure Value Set with Ambulatory Surgery UBREV Value Set and Ambulatory Surgery POS Value Set.

This will be corrected in the next release of the manual.

IHA 2013

No. The HEDIS 2015 Value Set Directory will not include invalid ICD-9 codes; it will only include ICD-9 codes that are valid for billing. The HEDIS 2014 value sets included invalid ICD-9 codes; these will be removed, effective with HEDIS 2015.

HEDIS 2014

No. Because of the delay in ICD-10 implementation, ICD-10 codes will not be used during P4P MY 2014 and therefore will not be included in the P4P MY 2014 Value Set Directory.

Purchasers of the P4P MY 2014 Value Set Directory will receive a separate file with ICD-10 codes proposed for inclusion in future releases of P4P specifications, but the codes will not be considered part of the MY 2014 measure specifications.

IHA 2013

A mental, behavioral or emotional disorder according to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, in members 18 years and older, that results in functional impairment which substantially interferes with or limits one or more major life activities (e.g., maintaining interpersonal relationships, activities of daily living, self-care, employment, recreation) that have occurred within the last year. All of these disorders may have acute episodes as part of the chronic course of the disorder. An organization may also use its state's definition or the definition of another appropriate regulatory authority.

Yes. RR 5, Element C is NA for individual plans and family plans offered under the Exchange because they are purchased directly by individuals and not plan sponsors.