FAQ Directory

UM Information Integrity oversight requirements related to UM request receipt and UM decision notification dates may be scored Not Applicable (NA) for delegates that only perform approvals and/or recommendations. Please note that this exception does not apply to delegates that make denial decisions.
Factors 5–7 are limited to the evaluation of UM receipt and notification dates.

Applicable standards:

• Health Plan Accreditation: UM 12, Element C, factors 5–7
• Utilization Management Accreditation: UM 8, Element C, factors 5–7
• Behavioral Health Accreditation: UM 10, Element C, factors 5–7

This applies to the following Programs and Years:

For the purposes of Accreditations in Health Outcomes and Community-Focused Care, a health plan that is seeking accreditation that provides both payor and provider functions (i.e., direct medical or behavioral patient care) is considered both a payer and a care delivery organization. “Direct medical or behavioral patient care” is not intended to include case management for the purposes of Accreditations in Health Outcomes and Community-Focused Care.

A health plan that provides direct medical or behavioral patient care must also meet the following requirements that apply only to care delivery organizations:

• HO 2, Element E.
• HO 2, Element H, factor 5. 
• HO 2, Element I, factor 5.
• HO 2, Element J, factor 5. 
• HO 4, Element A. 
• HO 4, Element B. 
• HO 5, Elements D and E. 

A health plan that does not provide direct patient care is not considered a care delivery organization. It is considered a payer only. The requirements listed above that apply only to care delivery organizations would not apply to a health plan that is a payer only.

This applies to the following Programs and Years:

If delegates that render medical necessity determinations do not have access to, manage, or handle UM request receipt dates or UM decision notification dates for any client—and no receipt or notification dates are stored in the delegates’ systems—then UM 12, Element C, factors 5–7 may be scored Not Applicable (NA), because the intent of these factors is to evaluate the integrity of receipt and notification dates.

If an organization retains sole responsibility for receiving UM requests, documenting receipt dates, and issuing UM decision notifications—and its delegates render medical necessity determinations only—then UM 12, Element C, factors 5–7 do not apply to those delegates.

Applicable standards:

• Health Plan Accreditation: UM 12, Element C
• Behavioral Health Accreditation: UM 11, Element C
• Utilization Management Accreditation: UM 8, Element C

This applies to the following Programs and Years:

No. For NCQA Health Plan Accreditation, NCQA reviews and scores UM 1, Elements B–H separately for each product line brought forward for Accreditation. Organizations may not combine any product lines—including commercial and Exchange—when reporting and evaluating UM rates for UM 1, Elements B–H.

Applicable standards: 

• Health Plan Accreditation: UM 1, Elements B-H.  
• Behavioral Health Accreditation: UM 1, Elements B-F. 
• Utilization Management Accreditation: UM 3, Elements B-H. 

This applies to the following Programs and Years:

No. Organizations must use 12 months of continuous data and may use data from the most recent calendar year (e.g., January 1–December 31). The workbook must be completed at least once during the look-back period. 

Applicable standards: 

• Health Plan Accreditation: UM 1, Elements B-H.  
• Behavioral Health Accreditation: UM 1, Elements B-F. 
• Utilization Management Accreditation: UM 3, Elements B-H.

This applies to the following Programs and Years:

For buprenorphine injection dispensing events identified using a medication list, if the days supply is not available in the pharmacy data, count as a 31 days supply.

This applies to the following Programs and Years:

Yes, NCQA recently identified and corrected an internal administrative error related to the Osteoporosis Management in Women (OMW) measure.

As part of NCQA's routine oversight process for all measures, certain value sets related to quantitative ultrasound (QUS) were prematurely removed from the OMW measure specifications. They have since been reinstated for measurement year 2026.

The value sets are now undergoing further assessment as part of a broader examination of the Osteoporosis measure bundle, consistent with NCQA’s ongoing efforts to ensure measures are aligned with scientifically sound and methodologically credible standards of care. Any future updates to value sets will be made and communicated in accordance with established notification requirements.

NCQA regrets any confusion this may have caused.

The updated HEDIS MY 2026 Value Set Directory was made available on April 15 to all purchasers of HEDIS MY 2026 Volume 2 publication through the My Downloads section of My NCQA. The April version of the Value Set Directory must be used for HEDIS MY 2026 reporting.

This applies to the following Programs and Years:

Yes, the CAHPS survey would meet the intent of AC 01. Specifically, the combined use of the following two questions would meet the intent of AC 01, as organizations will be able to draw implied preferences, based off customer responses.

When you needed care right away, how often did you get an appointment as soon as you needed?

• Never
• Sometimes
• Usually
• Always

When you made an appointment for a check‑up or routine care, how often did you get an appointment as soon as you needed?

• Never
• Sometimes
• Usually
• Always

The intent of the AC 01 is that the practice assesses the needs and preferences of the patient.  The rationale for this is since these questions would allow organizations to draw actionable insights to meet the needs and preferences of their patient population, based off the completed responses. 
 

This applies to the following Programs and Years:

Yes. There were changes to the TSC-E measure with the release of the HEDIS MY 2026 Volume 2 Technical Update on 3/31/2026. These changes to the age criteria in the measure are shown in red text in the re-released HEDIS MY 2026 Volume 2 e-pub.

The TSC-E FAQs posted on 1/15/2026 no longer apply and have been removed from the HEDIS FAQ website. The re-released HEDIS MY 2026 Volume 2 e-pub can be downloaded from the My Downloads section of My NCQA.

This applies to the following Programs and Years:

This applies to the following Programs and Years:

NCQA is retaining the childhood and adolescent immunization measures in HEDIS, and as a factor in NCQA’s Health Plan Ratings.

NCQA is aware of the updates made by the CDC and HHS to the child and adolescent immunization schedule. The 2025 HEDIS measurement data has already been collected according to the HEDIS MY 2025 CIS-E and IMA-E measure specifications. As a result, NCQA is not making any changes to HEDIS MY 2025 measure reporting requirements or to Health Plan Ratings 2026 scoring based on HEDIS MY 2025 data.  

This applies to the following Programs and Years:

Yes. Depending on the data generated for the mammography procedure, one procedure can be included as more than one episode in the initial population. The HEDIS MY 2025 measure specifications for DBM-E and FMA-E do not include steps to deduplicate mammography episodes where a procedure is represented multiple times in available data. For example, a mammography procedure can be represented in multiple claims (e.g., professional and facility claim) or within multiple data types (e.g., claim and clinical encounter). There are no steps in the measure specification to deduplicate across those data. Therefore, organizations reporting the measures can observe that a mammography procedure can be included as more than one episode in the initial population.

Organizations are allowed to deduplicate if there is a mechanism to confirm that the mammography procedures represented in the data represent the same episode. Please note that automated deduplication based on date of service is not appropriate as there may be multiple mammography procedures on the same day.  

The DBM-E and FMA-E measures are newly introduced for HEDIS MY 2025. Organizations that participate in reporting first-year measures are appreciated. Their reported results will not be public. The first-year results are used by NCQA to identify additional measure development needs and confirm the feasibility, reliability and validity of the measures prior to moving them to public reporting status. 

This applies to the following Programs and Years: