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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10.15.2013 Clarification that MED elements are NA for Exchange Product Line. Is the Exchange product line NA for the Medicaid standard and elements?

Yes. Organizations being surveyed for the Exchange product line are scored NA for all MED elements.

10.15.2013 Mental Health Utilization On page 302 of HEDIS 2014 Volume 2, in the Outpatient and ED section, the 5th bullet states "where the organization can confirm that the visit was in an intensive outpatient or partial hospitalization setting (POS 53 is not specific to setting)." Should the language be changed to reference an "outpatient" setting?

Yes. The language should read, "where the organization can confirm that the visit was in an outpatient setting (POS 53 is not specific to setting)." The intent is to include only codes where the organization can confirm that the visit was in an outpatient setting.

HEDIS 2014

10.15.2013 Meeting UM 7C and 7F using the Notice of Denial of Medical Prescription Drug Coverage. Does the Notice of Denial of Medicare Prescription Drug Coverage meet the same factors in UM 7, Elements C and F as the Notice of Denial of Medical Coverage (NDMC)?

Yes. NCQA accepts the Notice of Denial of Medical Prescription Drug Coverage as meeting factors 1-3 of these elements.

UM-CR 2013

10.15.2013 Identification of Alcohol and Other Drug Services On page 298 of HEDIS 2014 Volume 2, in the Outpatient and ED section, the 5th bullet states "where the organization can confirm that the visit was in an intensive outpatient or partial hospitalization setting (POS 53 is not specific to setting)." Should the language be changed to reference an "outpatient" setting?

Yes. The language should read, "where the organization can confirm that the visit was in an outpatient setting (POS 53 is not specific to setting)." The intent is to include only codes where the organization can confirm that the visit was in an outpatient setting.

HEDIS 2014

10.15.2013 Scoring and implementation of new Medicaid language in HP 2014. The 2014 HP standards state that beginning July 1, 2014, Medicaid plans will be reviewed and scored on MEM standards, but may submit a plan for implementing the MEM standards by July 1, 2015 (if the functions are not already in place). What is required of organizations that have surveys before July 1, 2015? What documentation is required of these organizations? Similarly, what is required of organizations that have surveys on or after July 1, 2015?

For Medicare, Medicaid and Exchange surveys beginning on or before June 30, 2015, NCQA will review and score the organization on their submitted implementation plan. The implementation plan must address all requirements of the applicable elements and factors, during the first year of review (July 1, 2014-June 30, 2015). NCQA will not resurvey or reevaluate organizations in 2015 to determine if MEM functions are operational. For Medicare, Medicaid and Exchange surveys beginning on or after July 1, 2015, the organization must demonstrate that MEM functions are operational in order to receive the associated points. We do not expect organizations to submit additional documentation between surveys.

8.29.2013 Documentation requirement for CVOs using the NPBD-PDS What documentation expectations are there for CVOs that use the NPDB-PDS for collections and reporting of sanction information?

The CVO must provide NCQA with evidence of current or continuous enrollment of the practitioner in the NPDB-PDS, and of review and reporting of NPDB-PDS activity within 120 calendar days to the organizations client. If no sanction information is reported by the NPDB-PDS, the CVO must provide documentation of this in the file and must report to clients that no sanctions were reported. The organization determines its method of documentation.

8.29.2013 Expiration date for board certification not provided by ABMS member board American Board of Pediatrics How should organizations handle NCQA's expiration date and timeliness requirements if the Medical Board does not provide an expiration date for a practitioner's board certification?

If the medical board does not provide the expiration date for a practitioner's board certification, the organization must verify that the board certification is current. Verification must be documented 180 calendar days prior to the recredentialing decision date.

8.29.2013 Use of Web crawlers for collection of credentialing information Does NCQA accept automated verifications obtained by a Web crawler or Internet grabber used in credentialing software?

Yes, if such mechanisms can legitimately access, retrieve and share the data from approved/recognized sources. All credentialing documentation requirements must be met, and there must be clear documentation that the organizations staff reviewed the credentialing information.

8.29.2013 Documentation requirements using NPDB-PDS Databank What are the documentation expectations for CVOs that use the NPDB-PDS Databank's Continuous Query for collecting and reporting malpractice history?

The CVO must provide NCQA with evidence of a practitioners current or continuous enrollment in the NPDB-PDS Databank, and of review and reporting of databank activity to the organizations client within 120 calendar days.

If no malpractice history is reported by the databank, the CVO must document this in the file and must report to clients that no malpractice settlements were reported. NCQA does not prescribe how the organization documents this information.

8.29.2013 Lack of expiration date for board certification What is NCQA's documentation requirement if a medical board does not provide an expiration date?

If the medical board does not provide the expiration date for a practitioner's board certification, the organization must verify and document that the board certification is current within 180 calendar days of the credentialing decision date.

8.29.2013 Verification of certification for an unrecognized board Does NCQA only accept ABMS and AOA sponsored boards as verification sources? What does NCQA require for verification of boards from non-ABMS or non-AOA boards if the practitioner claims to be board certified?

No. With the exception of ABMS or AOA sponsored boards, NCQA requires organizations to determine and list specialty boards they accept within their credentialing policies and procedures. At a minimum, at least annually, organizations must obtain confirmation from specialty boards that they perform primary-source verification of education and training. A specialty board that provides annual written confirmation that it conducts primary source verification of education and training can be used as an acceptable source for verification of education and training if the organization names the specialty board in its policies and procedures.

The organization must verify board certification status for any practitioner claiming to be certified by an ABMS or AOA sponsored boards, or by a specialty board recognized by the organization.

8.29.2013 Verification of board certification Does NCQA require board certification for practitioners to be included in an organizations network?

No. NCQA does not require board certification for practitioners to be included within its network.