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 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

1.29.2015 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 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:

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

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