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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9.15.2014 Comprehensive Diabetes Care For the eye exam indicator, is documentation of hypertensive retinopathy treated differently from diabetic retinopathy? If there is documentation that a member was negative for hypertensive retinopathy in the year prior to the measurement year, is this compliant?

 Although the two diagnoses are clinically different, hypertensive retinopathy is not treated differently from diabetic retinopathy for the CDC measure. The intent of the eye exam indicator is to ensure that members with evidence of any type of retinopathy have an eye exam annually, while members who remain free of retinopathy (i.e., the retinal exam was negative for retinopathy) are screened every other year. If it is clear that a retinal or dilated eye exam was performed by an eye care professional in the year prior to the measurement year and there is documentation indicating that the member is negative for hypertensive retinopathy, this can count as compliant.

 

HEDIS 2015

9.15.2014 Evidence-Based Cervical Cancer Screening (ECS) The MY 2014 ECS update reads, “Clarified that the lower age threshold in step 3 of Rate 1, step 2 of Rate 2 and step 3 of Rate 3, to account for the look back period, should be 33 instead of 30.” Why does age 30 continue to be used in Rates 1, 2 and 3?
In the Administrative Specification, Rate 1, step 3 reads, “For women 30–65 years as of December 31 of the measurement year …”

The age band for this measure was not changed; the language and age referenced in the steps were clarified to account for the look-back period. For the steps pertaining to the cervical cytology and HPV co-tests, because a woman must have been “30 years or older on the date of both tests,” and the tests must have been performed in the third or fourth year prior to the measure year, look only at women 33 and older.
This change was inadvertently left out of Rate 1, step 3. The final release of the MY 2014 P4P Manual on December 1, 2014, will contain the correct language.
For the descriptions of Rates 1, 2 and 3, however, the age bands have not changed; the measure aligns with current guidelines and looks at women 30–65 years of age.

IHA 2014

9.15.2014 General Guidelines Should the change to the logic from HEDIS 2015 General Guideline 41 also be applied to IHA measures that require results from the most recent test?

Yes. HEDIS 2015 General Guideline 41 will be adapted for P4P and added to the final version of the MY 2014 P4P Manual, which will be released on December 1, 2014. The guideline, like HEDIS, will apply to the CDC HbA1c control indicators.

IHA 2014

9.15.2014 PHQ: Evidence for seeking input from consumer representatives What evidence must an organization provide to meet the requirement for seeking input from consumer representatives?

The organization must provide a documented process for seeking and receiving input from consumers or consumer groups, and provide reports or materials showing that feedback was solicited and received.
The solicitation must address measures included in the program and how information about physicians is reported.
NCQA defines “consumers” as a non-health care professionals who have, or would, utilize health care services. NCQA defines “consumer groups” as organizations that advocate for people who are actual or potential users of health care services.

PHQ 2013

9.15.2014 Policies and Procedures: Accreditation status and Evaluation Option selection If a Marketplace product line is added to an existing product line through the automatic accreditation add-on process, when the Marketplace product line comes through again, what evaluation option will it be reviewed under, and what status will be available?

An NCQA-Accredited organization that received automatic accreditation via the Marketplace Add-On process may have the Marketplace product line reviewed against the First or Renewal Evaluation Option at the time of its Renewal Survey.
The organization must submit separate Survey Tools for an option other than a Renewal Survey.

The available accreditation statuses, elements reviewed and look-back periods are specified in the standards and guidelines for the selected Evaluation Option. 

For First and Renewal Surveys, the accredited status is valid for up to 36 months.

9.15.2014 Comprehensive Diabetes Care If a member is numerator negative for at least one indicator in the CDC measure, when may the optional exclusions be applied?

  The optional exclusion criteria may be applied only if the member did not have a diagnosis of diabetes during the measurement year or the year prior to the measurement year. If the member was included in the measure based on claim or encounter data, as described in the event/diagnosis criteria, the optional exclusions do not apply because the member had a diagnosis of diabetes. If the member was included in the measure based on pharmacy data alone, the member may meet criteria for an optional exclusion if no diagnosis of diabetes was found in claim or encounter data or in the medical record.

For example, if a member was included in the measure based on pharmacy data but had a visit with a diagnosis of diabetes, the member does not meet optional exclusion criteria.

If a member was included in the measure based on pharmacy data alone and there was no claim or encounter with a diagnosis of diabetes, but medical record documentation indicated the member is a diabetic, the member does not meet optional exclusion criteria.

If a member was included in the measure based on pharmacy data alone and there was no claim or encounter with a diagnosis of diabetes and no evidence of diabetes in the medical record being reviewed, the member may meet optional exclusion criteria if there was a diagnosis of polycystic ovaries any time during the member’s history through December 31 of the measurement year, or a diagnosis of gestational diabetes or steroid-induced diabetes during the measurement year or the year prior to the measurement year.

 

HEDIS 2015

9.15.2014 Osteoporosis Management in Women Who Had a Fracture Step 4 states to exclude members who received a dispensed prescription or had an active prescription to treat osteoporosis during the 365 days (12 months) prior to the IESD. Define “active prescription.”

 An “active prescription” means that a member has a surplus of medication to take from a prescription dispensed previously. Therefore, in step 4 (required exclusions), the member is excluded if a prescription was dispensed during the 12 months prior to the IESD, or prior to that time frame if the member has remaining pills to take in the 12 months prior to the IESD.

 

HEDIS 2015

9.10.2014 MEM: Clarifying after-hours response turnaround time for MEM3 Element B and MEM 5 Element B What is NCQA's expectation for organizations responding to calls after normal business hours for MEM 3, Element B and MEM 5, Element B?

An organization that does not have a voicemail system should have other means for identifying member calls after normal business hours, and return members’ call on the next business day.​

8.18.2014 HP 2014 UM 8E: Federal guidelines and external reviews Does UM 8, Element E apply if an organization follows federal guidelines for external reviews?

Yes. If an organization informs NCQA that it follows the Affordable Care Act requirements for external reviews (PHS Act section 2719), UM 8, Element E applies, even if the state where the organization operates does not comply with federal regulations.

8.15.2014 Plan All-Cause Readmissions In the step 5 examples, how do you determine if an acute inpatient stay is excluded? In example 2, why is Stay 1 not excluded?

To determine if a stay should be excluded, identify the index hospitalization and the FIRST readmission (if there is one). If the FIRST readmission was planned for, drop the index.

So, for example 2:

Stay 1. Index hospitalization with unplanned readmission (stay 2): Include as index.
Stay 2. Index hospitalization with planned readmission (stay 3): Drop as index.
Stay 3. Index hospitalization with planned readmission (stay 4): Drop as index.
Stay 4. Index hospitalization with no readmission: Include as index.

Stay 1 is the index. Stay 2 is the first readmission to assess, but because it does not meet criteria for a “planned hospital stay,” stay 1 is not excluded.

 

HEDIS 2015

7.15.2014 Controlling High Blood Pressure Is a problem list in an office visit note considered undated?

No, if a problem list is found in an office visit note then it would be considered a dated problem list and the date of the visit must be used. A true problem list is a standalone document in the medical record that records a member’s conditions. It is typically located in a centralized section of the medical record (usually the front of the chart) and lists all diagnoses. In an EHR a problem list is present at all routine office visits.

If the documentation is part of the member’s medical history, progress note or office visit note, the date of the visit must be used as the date of the HTN confirmation and must be on or before June 30 of the measurement year. The representative BP reading must occur after the date when the diagnosis of HTN was confirmed.

 

 

HEDIS 2015

5.20.2014 Supplemental Data Guidelines If a patient does not remember the exact date and location of a test or procedure, what is the minimum acceptable documentation for satisfying the supplemental data requirement for this measure? How specific does this information have to be? May member-reported data be entered into a legal health record by staff members?

General Guideline 28 outlines the requirements for using member-reported supplemental data, which may be accepted only when accompanied by proof-of-service documentation from the legal health record. If proof-of-service documentation is not available, member-reported information on services rendered (patient history) are acceptable only if taken by a PCP as part of the member’s history. Information must be signed, dated and maintained in the member’s legal health record. General Guideline 29: Date Specificity addresses measures that include date requirements in order to achieve numerator compliance. Dates must be specific enough to determine that the event occurred during the period specified by the measure. 

 

IHA 2013