FAQ Directory

No. QI 2, Element C does not require bidirectional data sharing.

The intent of the requirement is for health plans to share data required for at least one HEDIS measure identified in QI 2, Element C. This enables behavioral health organizations to collect HEDIS measure data to meet NCQA’s Behavioral Health Accreditation program requirements. The health plan and the behavioral health entity collaboratively select the specific HEDIS measure(s), review the technical specifications outlined in Volume 2, and determine which data elements need to be shared to support accurate and efficient reporting.  

This applies to the following Programs and Years:

Members with an unknown or nonbinary gender do not qualify for the risk adjusted utilization measures (PCR, HFS, HFC, HFG, HFO, HFU, AHU, EDU, HPC, EDH) because these measures require a gender to assign age/gender weights. These members should be removed from the measures.

This is not a change; measure models have always included male and female weights. The use of the administrative gender codes for MY 2026 clarify which members are included in the initial population.

This applies to the following Programs and Years:

No. Each inpatient hospital stay does not need to be both acute and observation for direct transfer. When assessing for direct transfer, include those with acute inpatient to acute inpatient, observation to observation, acute inpatient to observation and observation to acute inpatient.

This applies to both MY 2026 and MY 2025

This applies to the following Programs and Years:

Yes. The HEDIS MY 2026 Technical Update will remove HCPCS G0136 from the measure’s screening numerators and remove ICD-10 Z codes from the measure’s intervention denominators. The measure will continue to rely on LOINC codes for documentation of standard screenings and positive screening results. Additionally, NCQA will update some intervention procedure value sets to align with current code lists.

This applies to the following Programs and Years:

NCQA updated the look-back period on the Medi-Cal Rx Crosswalk for UM 11, Element E to be “prior to the survey date” for the 2025 standards year. This applies to California Medicaid organizations only. 

The look-back period should read:

For Interim Surveys: Prior to the survey date for all Elements.
For First Surveys: 6 months for Elements A-D; prior to the survey date for Element E.
For Renewal Surveys: 12 months for Elements A and C; at least once during the prior year for Elements B and D; prior to the survey date for Element E.

This applies to the following Programs and Years:

No. Organizations must use the exact calculated average to determine the element score. Rounding is not allowed.

For example, a calculated average of 2.8 does not meet the required threshold of 3.0, and the element is scored “Partially Met.”

This applies to the following Programs and Years:

Any coded response (any non-null response—positive or negative) on a pre-specified instrument for food, housing and transportation counts for completed screening numerators (numerators 1, 3, 5), with the exception of the PRAPARE Food Insecurity Instrument question (LOINC code 93031-3). Based on how the question is structured and responses are coded, a “No” or “None of the above” response cannot be coded, and must be left null; thus, a null response meets criteria for this item only. 

This applies to the following Programs and Years:

No. The PHQ-A is a different tool than the PHQ-9M, and is not included in Depression Screening and Follow-Up for Adolescents and Adults (DSF-E), Prenatal Depression Screening and Follow-Up (PND-E) and Postpartum Depression Screening and Follow-Up (PDS-E).

Plans may map appropriate screenings and results from any pre-specified tool to the LOINC codes in the specifications. If the core 9 questions in the PHQ-A are the same as those in the PHQ-9M, the same LOINC may be mapped.

Auditors review all code mapping as part of the annual review.

This applies to the following Programs and Years:

The Volume 2 BCS-E specification identifies the data elements for the SES stratification in Data Element Table BCS-E-B-3. Although the table includes a data element for “Total,” a Total will not be included for SES stratifications when the IDSS is released.

This discrepancy will not affect organizations reporting BCS-E through the IDSS, because “Totals” are calculated values in the IDSS and are not included in an organization’s XML file.

The IDSS will not calculate a “Total” for the SES stratification; a “Total” is already calculated from the age stratifications, and would be redundant.

This applies to the following Programs and Years:

Yes. Given the audit’s current and future importance, NCQA will use the HEDIS MY 2026 Technical Update to add program information to the Volume 2 publication.

This information resides in HEDIS Volume 5 and the Audit Program Code of Conduct. Adding it to Volume 2 enhances the information’s accessibility for all organizations participating in HEDIS.

Anticipate additional information in the following Volume 2 sections:  

NCQA HEDIS Compliance Audit Program Description

• References to the standardized HEDIS Compliance Audit methodology: All Licensed Organizations and Certified HEDIS Compliance Auditors use this method without deviation. All health plans reporting HEDIS are held to the same standards and requirements in HEDIS Volume 5. 
• References to the strict requirements for audit independence: All Licensed Organizations and auditors must avoid conflicts of interest, including perceived conflicts of interest, and are prohibited from providing technical assistance or advisory services to organizations that they audit. Noncompliance may result in revocation of licensure and certification status.

General Guideline: Preparing for the Audit

• A description of supplemental data validation: Information will summarize requirements and timing for all supplemental data sources undergoing validation. 
• A description of preliminary rate review: Information will summarize requirements for preliminary rate submission through the IDSS, and emphasize expectations for organizations to substantiate changes in performance rates.

This applies to the following Programs and Years:

As long as you submit scorable rates for at least 50% of the HPR measures by weight, per applicable product line and have a numerical rating (1-5) on at least one subcomposite under all three composites, we will calculate and display your measure rates and a numerical overall rating (0-5) on the September 15 release of HPR on the NCQA Health Plan Report Card.

This applies to the following Programs and Years:

Member-reported data are allowed in specific scenarios, and when all requirements are met.

Organizations may not call members to collect HEDIS data. The expectation is that member-reported data are generated during an encounter where the member receives care.   

Some HEDIS data are reported by members; for example, when standardized assessment tools are used (e.g., PHQ-2), or when documenting language preference, race and ethnicity.  

Services and biometric values reported by members are permitted if they adhere to the following guidelines in HEDIS Volume 2:

• Member-Reported Services and Biometric Values general guideline. Member-reported services may be used if collected by a PCP or specialist (if the specialist is providing a primary care service related to the condition being assessed, in the course of taking a member’s history), and if the information is in the member’s health record. 
• Supplemental Data general guideline.
  Information on services reported by members often reside in non-standard supplemental sources. The supplemental data general guideline states that there must be evidence of provider accountability for the information documented. Documentation of member-reported services must be complete (date, place of service, procedure, prescription, test result or finding, practitioner type).

This applies to the following Programs and Years: