NCQA Compliance

HEDIS is a set of standardized performance measures and includes more than 90 measures across 6 domains of care:

• Effectiveness of Care
• Access/Availability of Care
• Experience of Care
• Utilization and Risk Adjusted Utilization
• Health Plan Descriptive Information
• Measures Collected Using Electronic Clinical Data Systems
  • Administrative collection:  Claims based data (CPT, CPT-II, HCPCS, ICD-10, etc.)
  • Hybrid collection:  Claims data supplemented by medical records data
  • Survey data – Provider and member surveys

HEDIS measures contribute to NCQA ratings and was designed to allow consumers to compare health plan performance across plans and against benchmarks.

Click here for additional information regarding HEDIS.

CAHPS is a standardized survey of patients’ experiences with ambulatory and facility-level care in commercial and Medicaid plans developed with the Agency for Healthcare Research and Quality (AHRQ). CAHPS measures:

• patient ease of obtaining information from a health plan
• timeliness of service
• speed and accuracy of claim processing

Care coordination is more than helping Members stabilize their uncontrolled health conditions. An integral part of your role is to assist providers with creating strategies and best practices that result in achieving Population Health Management (PHM) goals.

Directly
As Care Coordinators, it is important that all of your documentation meets the NCQA Standards (D1-5 E1-11).

Indirectly
In addition, you can influence how providers resolve their Members’ “gaps in care” as well as support their efforts to address the Core 10 HEDIS measures that are identified on the PCMH Quality Scorecard.

By using proper documentation:

• All Care Plan goals must be Specific to the Member’s health condition, Measurable, Achievable, Realistic and Time-bound
• Documentation must meet current NCQA Standards  (D1-5 E1-11).
  
  • The use of check boxes, checklists, or radio buttons is not sufficient for NCQA.
  • To meet standards, all comment boxes in the Care Plan sections must provide further detail to describe and support the selection made.
  • Care Plans will be reviewed for these standards during the Care Plan Review process
• Documentation must address the Member’s Social Determinants of Health.
• Initial Assessments must be started within 30 calendar days and completed within 60 calendar days of the in-development date of the care plan
• Care Plans must:
  
  • be tailored for each Member and prioritized with goals.
  • address the Member’s barriers.
  • Include the Member’s acknowledgement of and agreement with the plan.
  • include a Preventive Plan to address Gaps in Care.
• Weekly calls must indicate the next contact communication with Member, including the time or time frame and method of communication.

Below are some NCQA documentation resources:

• Standard Operating Procedures and Policies
• Care Plan Documentation Templates
• Helpful Hints: NCQA Documentation
• Reference Tool / Rubric (Sunset May 2020)

If CareFirst meets the benchmark, then we receive a 5 Star Rating from NCQA.

Click here to learn more about NCQA and our rating. 

Image 2.0 shows CareFirst’s 2017 -2018 CareFirst NCQA Report Card and Rating.