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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11.15.2013 Effective dates of specificity requirements in Delegation Agreements For Element A in all standard categories in delegation (QI 12, UM 15, CR 9, RR 7, MEM 9), will existing delegation agreements be grandfathered if they do not meet the specificity required in the 2014 Written Delegation Agreement elements?

No. All existing delegation documents must be modified to reflect the specificity requirements before January 1, 2015. All new delegation documents that were effective on or after October 1, 2013, must meet the specificity requirement for standard year 2014.

11.15.2013 Scoring Cervical Cancer Screening in 2014 How will organizations be scored on the Cervical Cancer Screening (CCS) measure for HEDIS 2014 reporting?

All organizations will be scored NA for 2014 reporting due to significant specification changes. However, the NA will not count against the eight NA thresholds used to covert to Standards plus CAHPS or Standards Only scoring.

11.15.2013 Initiation and Engagement of Alcohol and Other Drug DependenceTreatment The list of code combinations to identify Initiation and Engagement visits do not include codes to identify inpatient admissions. Do inpatient admissions count as initiation and engagement of AOD treatment?

As stated in the paragraphs prior to the list of code combinations, an inpatient admission with a diagnosis of AOD meets criteria for both initiation and engagement. Because NCQA does not specify codes to identify inpatient admissions, inpatient admissions were not included in the list of code combinations. The lists of code combinations include only visits for which value sets exist (outpatient, intensive outpatient and partial hospitalization). Organizations should use their own methods for identifying inpatient admissions when identifying initiation and engagement visits.

HEDIS 2014

11.15.2013 Practitioners listed in the directory that require credentialing Are practitioners listed in the directory within the scope of credentialing?

Yes. Practitioners listed in the organization directory must be credentialed.

11.15.2013 Value Set Directory The Summary of Changes spreadsheet in the HEDIS 2014 Volume 2 Value Set Directory lists LOINC code 72732-0 as added to the Sexual Activity Value Set, but that code is not in the Volume 2 Value Sets to Codes spreadsheet.

LOINC code 73732-0 was added to the Sexual Activity Value Set; it was entered incorrectly (as 72732-0) in the Summary of Changes spreadsheet. We apologize for the inconvenience.

HEDIS 2014

11.15.2013 Information required in HA disclosures Is the organization required to explain how it assesses member understanding in the health appraisal under MEM 1, Element B, factor 4?

No. Such a statement is not needed in the health appraisal, although the organization is required to have a process for assessing member understanding of the information required by factors 1_3. For factor 4, NCQA reviews the organization's documented process for evaluating understandability of HA disclosures.

11.15.2013 Routine dental and vision care under medical benefit For UM and CR, are routine dental and vision care considered part of the medical benefit for the Exchange product line?

No. Although routine dental and vision care are included as essential benefits as part of the Affordable Care Act, NCQA was approved for its current requirements as an accrediting organization for Exchanges. Because routine dental and vision care are not included in the benefit requirements or utilization management, we will not survey them for 2013 and 2014 health plan accreditation.

11.15.2013 Volume 2 Technical Update In the Volume 2 Technical Update memo, the term "discharged alive" was replaced with "discharged" in measures that include discharges for AMI or CABG. Does this mean that members who died prior to discharge should be included in the measures?

No. Removal of the language "discharged alive" does not mean that deceased members should be included in measures. As with other HEDIS measures, deceased members who do not meet continuous enrollment or anchor date criteria should not be included in the measures Eligible Population. The term "discharged alive" was removed in order to make language consistent across AMI, CABG and PCI (the term had been removed from PCI in the July 1 release of the publication; NCQA received questions about why it was removed from PCI but not from AMI or CABG). In 2015, NCQA intends to remove the term "discharged alive" from all remaining references (i.e., PBH, FUH and all measure descriptions).

HEDIS 2014

11.15.2013 General Guidelines Have the dates been extended for primary source verification (PSV) and final approval of supplemental data for HEDIS 2014?

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

HEDIS 2014

10.15.2013 Core and Structural elements. What is the difference between core elements and structural elements?

Core elements are requirements that an organization must meet even if it has no clients.

Structural elements are requirements that the organization must meet even if it delegates 100% of the function. If an organization delegates the functions associated with a structural requirement, it must provide NCQA with its own programs or policies and procedures and evidence of approval of the delegates documentation.

UM-CR 2013

10.15.2013 Commercial and Medicare Exchanges. Do private commercial and Medicare exchanges come under the Exchange product line?

No. The Exchange product line is only for the public (ACA-related) exchanges. Private commercial exchanges come under the commercial product line and Medicare exchanges come under the Medicare product line.

10.15.2013 Use of a vendor or delegate for HIP and WHP Certifications. May an organization coming through for HIP or WHP certification use a vendor or delegate for any functions or activities required by the standards and guidelines?

No. Organizations coming through for NCQA HIP or WHP Certification may not use a vendor or delegate for any functions or activities required by the HIP/WHP certification standards and guidelines.

WHP 2013