Abbreviations
KED
Kidney Health Evaluation
T/F
Exclusions fall into 2 categories: Required Exclusions and Optional Exclusions
FALSE
MY24 Removed the Optional Exclusions categories- All member exclusions are required
Name 2 "where to go" resources when data mining for labs (KED, A1c)
Labcorp
Quest
CPL
HIE
ChartFast
Datavant
Name 2 compliant timelines for COL-E & the type of test
FOBT- 1yr
FIT (Cologuard)- 3yrs
Sigmoidoscopy- 5yrs
Colonoscopy- 10yrs
Name the FIVE measures that can apply to people with diabetes
Part C: GSD, EED, KED
Part D: SUPD, MA-D
Breast Cancer Screening
BCS-E
Name 2 Exclusions for Breast Cancer Screening
Bilateral mastectomy, Unilateral mastectomy with bilateral modifier, Mastectomy of both left and right side (may be on different dates of service)
Hospice or palliative care, Death during measurement year, For members 66 and older – enrolled in I-SNP, living in a long-term care facility and/or meet both frailty and advanced illness criteria
Name "where to go" when uploading supplemental data
P3 Provider
Breast Cancer Screening
27 months
For MY 2026 - 10/01/2024 through 12/31/2026
A member has the following labs in their EMR record- are they compliant for MY26?
1.15.26: A1c 8.2%, 4.22.26: A1c 7.9%
6.26.26: A1c 8.5%, 11.15.26: A1c 9.2%
Non-Compliant A1c reading 9.2%
Transitions of Care
TRC
Do exclusions impact the numerator or the denominator in Quality scores?
Denominator
Name "where to go" when uploading supplemental data & the gap is NOT OPEN in P3 Provider
Share Drive Folder: "Gap Closing Documentation & Exclusions"
Eye Exam for Persons with Diabetes
1 Year for a Positive Retinal or Dilated Eye Exam (2026)
2 Years for a Negative Retinal or Dilated Eye Exam (2025)
Name the 2 labs needed to close the KED measure
uACR & eGFR
COB
Concurrent Use of Opioids & Benzodiazepines
Name 2 Exclusions for OMW
BMD (DEXA Scan) test that was performed within 24 months prior to the fracture,
Osteoporosis therapy within 12 months before the fracture,
Prescription to treat or prevent osteoporosis within 12 months before the fracture,
Patients in hospice,
Patients 67-85 years old living long-term in an institutional setting,
Patients 67-80 years old with frailty and advanced illness, or
Patients 81 years old or older with frailty only
Name "where to go" to find updated GIC files
RQC and National Quality Teams Channel Shared Drive - GIC Files
Transitions of Care
30 Days plus the date of discharge = 31 days
What can you upload to close SUPD?
NOTHING - Part D measures are claims based.
Exclusions can be uploaded if found
Use of Multiple Anticholinergic Medications in Older Adults
Poly-ACH
Define Frailty & Advanced Illness exclusion criteria
TWO instances of Frailty AND TWO instances of Advanced Illness
Name "where to go" to find the Learning Lab schedule
RQC and National Quality Teams Channel Shared Drive > Quality Team Meetings> Ice Breaker & SME Assignments 2026
Follow Up for Persons with Multiple Chronic Conditions
7 Days plus the date of discharge = 8 days
A member has their A1c taken in February and is recorded at 8.2%. In September, the member is on your GIC file again- explain why.
A 2nd A1c was taken after February & is out of range (non-compliant) & the member back on the GIC list.
Or its a DSAP error ;)