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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6.15.2013 Distribution of materials for Interim Surveys Where elements require materials as a data source for all survey types, must the materials be distribute for Interim Surveys?

Organizations going through Interim Survey must present materials to meet the requirements of the element. Materials are not required to have been distributed, and do not have to be in final layout form, but must be approved by the organization. Draft materials are appropriate if approved by the organization.

6.15.2013 Look-back period for Exchange products coming through Renewal Survey What is the look-back period for Exchange products coming through a Renewal Survey (i.e. concurrently with an existing NCQA Accredited product)?

The look-back period is prior to the survey date for the Exchange product line.

6.15.2013 Number of sets of minutes for Interim Surveys How many sets of minutes are required for Interim Surveys? Many organizations seeking Interim Accreditation will barely be able to have one or two meetings before survey, especially new health plans, like CO-OPs.

For Interim Surveys, NCQA reviews up to three minutes. If there are fewer than 3 meetings, the organization presents the minutes from the meetings it has held.

6.15.2013 Scoring for factors for Interim Surveys Factors 2, 4 and 5 require activities to have been in place for a period of time that is longer than is likely to be the case for organizations seeking Interim Accreditation, especially new health plans, like CO-OPs. How will these factors be scored?

5.16.2013 General Guidelines Does an ICD-9 code of "411" mean that only code "411" is to be used, or do we also include all successor codes: 411.0, 411.1, 411.81, 411.89?

Unless otherwise noted, codes are stated in the minimum specificity required. For example, if a three-digit code is listed, it is valid as a three-, four- or five-digit code. If a table lists ICD-9-CM Diagnosis code 401, the codes 401.0, 401.1 and 401.9 are acceptable for P4P reporting. When required, a code will be specified with an x, which represents a valid digit that must be used for reporting. For example, ICD-9-CM diagnosis code 640.x1 indicates that any valid fourth digit can be used if the fifth digit is 1.

5.15.2013 Monitoring Medicare Opt-Out Physicians May MA organizations use NPDB-HIPDB as a source of information for Medicare opt-out physicians?

No. The NPDB-HIPDB may not be used as a source for verifying a practitioner's status in relation to the Medicare Opt-Out Program. MA organizations can check with their states' Medicare Opt-Out list.

MA 2013

5.15.2013 When ER files are included in the universe of files for review When are ER denial files included in the universe of files for file review during an Accreditation or Certification Survey?

Generally, ER denials are not included in the universe of files for initial UM decisions unless a denial is appealed. In that case, the ER appeal is included in the universe of files for appeals.

UM-CR 2013

5.15.2013 Pay-for-performance Program If our organization displays information about our pay-for-performance program but does not display physician performance information for this program, how does NCQA score PQ 3A, 3B, 3C, 3D and 4B?

PQ 3A factors 3-5 and PQ 3B are scored NA if the organization does not display physician performance information for the pay-for-performance program.

PQ 3 C and D are scored against the pay-for-performance requirements if the organization has one complaint process for all programs. If the organizations complaint process is program-specific, PQ 3C and D are scored NA for the pay-for-performance program. NCQA scores PQ 4B factor 1 and the customer portion of factor 4 NA for the pay-for-performance program.

Because there is no NA scoring option in PQ 3B, 3C and 4B, these requirements are scored yes for pay-for-performance programs described above until the NA scoring option is added during the 7/29 release of the ISS tool.

PHQ 2013

5.15.2013 National Student Clearinghouse as a source for education and training Does NCQA accept the National Student Clearinghouse (NSC) as a source for education and training?

The NSC is not recognized by NCQA as a source for education and training. However, the NSC would be considered an agent of the medical or professional school if the school has a contract with the Clearinghouse to provide verification services. The organization must provide documentation that the specific school has a contract with the Clearinghouse.

UM-CR 2013

4.16.2013 Proportion of Days Covered (PDC) The specifications require a pharmacy benefit, but POs do not have access to pharmacy benefit information. How do we verify that a member has a pharmacy benefit, and the start and end dates for that benefit?

If a PO receives pharmacy claims for a member, it can assume that the member has a pharmacy benefit, and that the pharmacy benefit dates align with the medical benefit dates.

4.16.2013 Proportion of Days Covered (PDC) The measure specification does not have an anchor date. How do we attribute members without an anchor date?

The Index Prescription Date (IPD) can be used as the anchor date.

4.16.2013 Proportion of Days Covered (PDC) The specification requires a pharmacy benefit, but does not require a medical benefit. How do we identify and attribute members with only a pharmacy benefit?

Members with only a pharmacy benefit are not attributed to a PO, so they are not included in the measure.