Ideally, care gaps are closed by administrative data; however, there are many reasons why data may not be received by the plans. NCQA allows health plans to conduct a Hybrid review to validate that data is not being received administratively. NCQA determines if a measure is considered Administrative or Hybrid. If a measure is considered Administrative, the plans do not have the option to conduct a Hybrid review.
• Administrative Data: Various data sources are considered administrative data sources. Claims, Encounters, CAIR2, Pharmacy, and Lab data submitted through standard processes are all considered administrative data and are used to close care gaps.
• Hybrid: Health Plans have the option to conduct random medical record reviews using strict NCQA requirements to increase their performance rates. A set number of records are selected and requested from providers for review. Based on the outcome of this review, a plan has the potential to improve compliance rates for measures that are designated as Hybrid by NCQA.