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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2.15.2014 Clarifying delegation specificity requirement How specific must the delegation agreement be between the organization and the delegate with regards to outlining responsibilities?

The delegation agreement between an organization and its delegate must: 1. Specify activities performed by the delegate in detailed language relative to applicable NCQA standard categories. 2. Specify functions not delegated, but retained by the organization. Organizations may include a general statement in the agreement addressing retained functions (e.g., the organization retains all other QI functions not specified in this agreement as the delegates responsibility). Existing agreements may be updated with an addendum or communication (e.g., e-mail, spreadsheet, table) between the organization and the delegate, indicating that responsibilities were mutually agreed upon before the delegation agreement was final and outlining the responsibilities of each entity.

2.14.2014 Osteoporosis Management in Women Who Had a Fracture When determining the eligible population, step 4 states to exclude members with a dispensed prescription to treat osteoporosis (Table OMW-C) during the 365 days (12 months) prior to the IESD. Does this include only osteoporosis prescriptions dispensed during the 365-day look-back period, or may it include an osteoporosis prescription that was dispensed prior to the look back period but is still “active” during the 365 days?

Members with an “active” prescription for osteoporosis treatment (Table OMW-C) during the 365 days prior to the IESD meet the step 4 exclusion criterion. The prescription does not need to be dispensed during the 365-day look-back period. NCQA does not specify how long organizations must look back prior to the IESD to identify an “active” prescription; organizations determine the look-back period, which should be applied consistently across all members.

HEDIS 2014

2.14.2014 Inpatient Utilization General Hospital/Acute Care In step 4, the text under the "Medicine" bullet states for the Newborns/Neonates MS-DRG Value Set, "Do not include newborn care rendered from birth to discharge home from delivery; only report newborn care rendered if the baby is discharged home from delivery and is subsequently rehospitalized." In HEDIS 2013, this instruction also applies to "Total Inpatient." Should newborn care rendered from birth to discharge home from delivery also be excluded from Total Inpatient?

Yes. Exclude newborn care rendered from birth to discharge home from delivery before reporting Total Inpatient (step 3).

HEDIS 2014

2.14.2014 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents For the BMI percentile indicator, does documentation of >99% or <1% meet criteria?

Yes. Documentation of >99% or <1% may be used when reporting because an exact BMI percentile value is evident (i.e., 100% or 0%). These examples are not considered ranges or thresholds, which are not permitted when reporting the BMI percentile indicator. Examples of non-permitted ranges and thresholds are "75-80th percentile" and ">90th percentile" because the exact BMI percentile value is not evident.

HEDIS 2014

2.14.2014 Non-Recommended Cervical Cancer Screening in Adolescent Females In the Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS) measure, how should the optional exclusions be handled given that a lower rate indicates better performance?

Based on the current guideline, organizations should look for optional exclusions only where administrative data indicate that the specified numerator service or procedure did not occur. For the NCS measure, the optional exclusions indicate a justification for screening so it is not inappropriate care if these members are screened. Therefore, the optional exclusions in the NCS measure were intended to be required exclusions. In HEDIS 2015, these members must be removed from the eligible population regardless of numerator compliance. NCQA Measure Certification for NCS is based on the HEDIS 2014 optional exclusion guideline, test decks will not be updated until HEDIS 2015 and vendors may not recertify. Vendors who still need to certify NCS must comply with the current test decks. If an organization chooses to remove these optional exclusions from the NCS eligible population (i.e., treat them as required exclusions) for HEDIS 2014, the organization should work with their HEDIS Compliance Auditor to identify and remove these members.

NCQA Measure Certification for NCS is based on the HEDIS 2014 optional exclusion guideline, test decks will not be updated until HEDIS 2015 and vendors may not recertify. Vendors who still need to certify NCS must comply with the current test decks. If an organization chooses to remove these optional exclusions from the NCS eligible population (i.e., treat them as required exclusions) for HEDIS 2014, the organization should work with their HEDIS Compliance Auditor to identify and remove these members.

HEDIS 2014

1.24.2014 Controlling Blood Pressure for People with Hypertension (CBPH) The MY 2013 P4P Manual does not contain a Hypertension Value Set in the Controlling Blood Pressure for People With Hypertension (CBPH) measure or in the Diabetes Care (CDC) measure referenced in the 12/20/13 P4P FAQ. Where can I find these codes?

The Hypertension Value Set was not included in the MY 2013 P4P Value Directory. The codes included in the Hypertension Value Set are:

  • ICD-9-CM 401.1.
  • ICD-9-CM 401.
  • ICD-9-CM 401.9.
  • ICD-9-CM 401.0.

The Hypertension Value Set will be included in the next release of the P4P Value Set Directory.

IHA 2013

1.24.2014 Meaningful Use of Health IT: Overview There appears to be an error in Table 1 of the Domain Structure in the Overview section of the MUHIT Survey. In the first column, there is an overlap in percentage groups 45_64 and 64_84. What are the correct percentage ranges for this table?

There is an error in the percentage ranges listed in Table 1: MUHIT Points for ONC-ATCB Certified Software. The range to receive 4 points is 65_84.

IHA 2013

1.24.2014 Evidence-Based Cervical Cancer Screening of Average-Risk Asymptomatic Women (ECS) Step 1 of the ECS Administrative Specification Rate 1 states, “Identify the number of women 24–65 years of age with hysterectomies who had cervical cytology.”

In the MY 2012 P4P manual, step 1 of Rate 1 in the ECS Administrative Specification says, “…who had NO Pap tests.” Should the text in the MY 2013 P4P Manual say, “who had NO cervical cytology”?

Yes. Step 1 of the ECS Administrative Specification Rate 1 should say, “…who had NO cervical cytology.”

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

IHA 2013

1.24.2014 Proportion of Days Covered by Medications (PDC) The Oral Diabetes Tab includes the NDC code 47463051060, which may be incorrectly assigned to a GCN. This NDC (47463051060—metformin) is assigned to GCN 71160. However, for other NDCs with the same generic drug name (metformin), route and GPI are assigned to GCN 89863. Which GCN is correct?

The NDC code 47463051060 (Metformin HCl Tab SR 24HR 500 MG) is incorrectly assigned to GCN 71160. The correct GCN is 89863.

This particular NDC was recycled to the medication metformin and therefore should have a GCN of 89863, rather than the previous GCN linked to the obsolete NDC.

IHA 2013

1.15.2014 Distribution of the Member's Rights and Responsibilities Statement May a delegate distribute the statement of members' rights and responsibilities?

Yes. Distribution of member rights and responsibilities statement by a delegate is acceptable. The organization must perform oversight to ensure that this requirement is met.

1.15.2014 Board Certification as Verification of Education and Training for Nurse Practitioners (NP) and Physician Assistants (PA) Is it acceptable to use ANCC and NCCPA board certification as verification of highest level of education for nurse practitioners and physician assistants?

Yes, if the organization can obtain written confirmation from the ANCC and NCCPA that they perform primary-source verification of the professional school training.

CVO 2013

12.20.2013 Supplemental Data Guidelines Have the dates been extended for primary source verification and final approval of supplemental data for P4P Measurement Year 2013?

Yes. Data collection and entry of all nonstandard and member-reported supplemental data must stop on March 3. Primary source verification and final approval must be completed by March 14, for member-reported supplemental data, and by March 28, for nonstandard supplemental data. Primary source verification may not occur before March 3 unless all supplemental data processes, collection and entry have stopped. Supplemental data approval and primary source verification may not occur, under any circumstances, before January 1 and receipt of the Roadmap.

IHA 2013