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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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.
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.
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.
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.
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.
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.
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.
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.
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.
