Yes. Although NCQA recommends that organizations using the Hybrid Method pursue charts for all noncompliant members in the systematic sample, ultimately, the decision is the organization’s.
Except for plans in Puerto Rico, which report all members in the “Unknown” category, it is expected that the member count in this category will be at or below 1%. If more than 1% of eligible members are assigned to the “Unknown” category, the plan must work with the auditor to identify why members are being categorized as “Unknown.”
No. Codes alone (without additional documentation of the service provided) do not meet criteria for proof of service. If a provider performs a service, it is expected that additional documentation exists in the medical record or in the primary source document. Auditors must validate, through primary source verification, all elements required by the administrative measure specification.
The exclusion in General Guideline 18 is optional. Members who die during the measurement year may be excluded from all measures, except the measures in the Health Plan Descriptive domain or the Risk Adjusted Utilization subdomain. However, if a member dies during the measurement year, the organization is not required to remove the member from all measures.
For example, if an organization identifies a deceased member during medical record review for the ABA measure, the member may be removed from the measure as a valid data error and replaced with a member from the oversample, but the organization is not required to remove the member from all other applicable HEDIS measures.
Additionally, there is no requirement to assess numerator compliance for deceased members and exclude the member only if they are not numerator compliant. NCQA does not prescribe how organizations identify deceased members using claim/encounter and enrollment data. Organizations must develop their own methods to identify these members.
Yes. Supplemental data may be used for the denominator and the numerator when following the Rules for Allowable Adjustments. In general, the data are usable when the codes are in the value sets and the clinical intent of the measure is not changed, but there are restrictions for use of supplemental data in regular HEDIS reporting:
Any NDC or RxNorm code that is in the U.S. National Library of Medicine’s RxNorm database as of September 1, 2019 will be considered for inclusion in the HEDIS 2020 MLD, which will be posted to the NCQA website on November 1, 2019. This is a change from past years’ cutoff date, which was September 30.
Except for plans in Puerto Rico, which report all members in the “Unknown” category, it is expected that the member count in this category will be fewer than 10. Plans should determine why members are reported as “Unknown” and be able to explain the reason to their auditor.
This category should not be used for members who are disenrolled for the 2019 calendar year and consequently have no record in the December 2018 Monthly Membership Detail File. Use the October and November files for these members.
General Guideline 25 in HEDIS Volume 2 explains that benefits are not assessed at the service level. Assessment of benefits must follow the measure specifications under the Benefit section of the Eligible Population criteria. Organizations may not assess benefits at a service level for an NB (No Benefit) audit designation.
· If the organization offers a pharmacy benefit but does not cover a specific medication class, the member has a pharmacy benefit and is included in the applicable measures requiring this benefit.
· If the organization offers a mental health benefit but does not cover inpatient visits, the member has a mental health benefit and is included in the applicable measures requiring this benefit, unless the measure benefit requires inpatient care, per the Eligible Population benefit requirements (e.g., Follow-up After Hospitalization for Mental Illness requires both inpatient and outpatient mental health coverage).
No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-C. Remove the “Total Medicare” row from Table PCR-D that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-C. The asterisked language may also be removed under these two tables.