Organizations must provide an IDSS report and/or a CMS Proof Sheet as evidence of reporting the required measures for the Exchange product line in QI 3, Element D.
HP 2025
FAQ Directory
Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can ask a question through My NCQA.
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6.16.2025 Evidence for QI 3, Element D: Exchange Reporting What types of evidence may an organization submit to demonstrate reporting of the required measures for QI 3, Element D?
6.16.2025 Clarifying the Definition of “Threshold Languages” How does NCQA define “threshold languages” for CM-LTSS Accreditation and LTSS Distinction in Health Plan Accreditation?
6.16.2025 QI 3, Element A: Applicability of Behavioral Healthcare Reported Measures How can an organization that reports measures for QI 3, Element A meet the 50% threshold if behavioral healthcare services are carved out and the organization therefore has a “No Benefit” audit designation for 6 of the 10 measures?
In this example, the organization may demonstrate compliance with QI 3, Element A by providing evidence that it reported 50% of required measures it is capable of reporting. The organization would be required to report a valid, numeric rate for at least 50% of the required nonbehavioral health measures (i.e., 2 of the 4).
HP 2025
6.16.2025 Conducting Audit of Effectiveness Quarterly If an organization chooses to complete its audit and analysis for the Information Integrity requirements quarterly, may it also complete the audit of effectiveness quarterly?
Yes. Organizations that choose to conduct their audit and analysis for Information Integrity more frequently than annually (i.e., quarterly), may also conduct the follow-up audit of effectiveness more frequently. The audit must be within the 3–6 month time frame prescribed by NCQA.
Applicable Standards:
HP: CR 8, Element C; CR 8, Element D, factor 2. UM 12, Element D, UM 12, Element E, factor 2; UM 12, Element F, UM 12, Element G, factor 2.
CRPN: CR 2, Element C, CR 2, Element D, factor 2.
MBHO: CR 8, Element C; CR 8, Element D, factor 2. UM 11, Element D, UM 11, Element E, factor 2; UM 11, Element F, UM 11, Element G, factor 2.
HP 2025
6.13.2025 TotalKnown Data Element for Language Diversity of Membership (LDM) Is the TotalKnown data element in Table LDM-A-1/2/3 and Table LDM-B-1/2/3 a calculated data element?
6.13.2025 Direct reference code POS 81 for Adult Immunization Status (AIS-E) POS code 81 is included in the AIS-E measure specification but is not included in the Direct Reference Code tab of the VSD. Should the code be used when reporting Adult Immunization Status for MY 2025?
Yes. As described in Numerator 5—Immunization Status: Hepatitis B, use POS code 81 to exclude laboratory claims when identifying members with a history of hepatitis B illness. POS code 81 was mistakenly omitted from the Direct Reference Code tab of the VSD. Because the information needed for reporting is in the measure specification, NCQA does not intend to reissue the VSD.
HEDIS 2025
5.15.2025 Medication List in Deprescribing of Benzodiazepines in Older Adults (DBO) In the MY 2025 Medication List Directory, three codes (NDC codes 00378027701, 00378027705; RxNorm code 856792) are included in both the Chlordiazepoxide 10 MG Medications List and the Chlordiazepoxide 25 MG Medications List. Should the codes be included in both lists?
No. The codes are for “amitriptyline hydrochloride 25 MG/chlordiazepoxide 10 MG Oral Tablet.” They belong only in the Chlordiazepoxide 10 MG Medications List. NCQA re-released the MY 2025 Medication List directory on May 15, 2025, to incorporate this update. NCQA’s Measure Certification program confirmed that certification organizations deleted the codes from the Chlordiazepoxide 25 MG Medications List. No changes to the current process are necessary.
HEDIS 2025
5.15.2025 CAQH Application and Antidiscrimination Statement Has NCQA been in communication with CAQH about including the new NCQA requirements for race, ethnicity and language on its application?
Yes. NCQA has worked with CAQH to add a notice to its practitioner- and customer-facing provider credentialing applications, recognizing that discriminatory uses of race, ethnicity and language data are prohibited. CAQH is going live with the application update on 7/1/25.
The use of the CAQH application will be acceptable to meet CR 3, Element C, factor 6: Race, ethnicity and language in the 2025 Health Plan Accreditation standards and guidelines (and applicable products).
This applies to:
HPA: CR 3, Element A, factor 6
CRPN: CRA 3, Element A, factor 6, CRC 10, Elements A, factor 6
MBHO: CR 3, Element A, factor 6
HP 2025
5.15.2025 Credentialing Application: Race, Ethnicity and Language (REL) Are separate fields required for race, ethnicity and language? For example, is the CAQH application acceptable to meet CR 3, Element C, factor 6, as the CAQH application collects race and ethnicity under one field and language in another?
The requirement is for the application to have separate fields to enter responses for each of these three data points (race, ethnicity, and language). However, it would be acceptable to group these into one question if the application prompts the user to provide separate responses for race, ethnicity and language.
Responses provided through the CAQH online portal for credentialing data application are acceptable. Although the online portal supporting the credentialing application groups the responses for race and ethnicity into one field, the practitioner is prompted to provide separate responses within the system. When a practitioner chooses his/her race, the practitioner is then prompted to provide his/her ethnicity information. Language is captured via a separate field.
This applies to:
HPA: CR 3, Element A, factor 6
CRPN: CRA 3, Element A, factor 6, CRC 10, Elements A, factor 6
MBHO: CR 3, Element A, factor 6
Note: A related question was posted on 3/17/2025: “Credentialing Application: Race, Ethnicity and Language (REL).” This FAQ is an update to that post.
HP 2025
5.15.2025 Vaginal Specimen Source for the CCS and CCS-E measures Does an HPV or Pap test that has a vaginal sample source meet criteria for the numerator?
4.15.2025 Using software to make medical necessity approval decisions May organizations use software to make medical necessity approval decisions?
Yes, if the software uses the organization’s clinical criteria, policies and procedures and benefit package information, and the organization maintains control over the software implementation. Organizations may not use the software to make any denial decisions; those must be made by an appropriate clinical professional. Appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.
NCQA considers the use of external software to make approval decisions to be a vendor relationship for applicable requirements (e.g., UM 4, Element F). Refer to Appendix 3: Delegation and Automatic Credit Guidelines for additional information.
HP 2025
3.17.2025 Recent Updates to the MA Deeming Module Do the new requirements found in CFR § 422.101(f)(2)(vi) for the Medicare Advantage (MA) Program that became applicable to MA Deeming requirements on January 1, 2025, apply to the 2024 and 2025 NCQA MA Deeming Module?
Yes. The following changes apply to SNP 2, Assessing and Coordinating Care.
NCQA added a new Element F, Contracts with Long-Term Care Institutions for I-SNP Members, that requires organizations to confirm that contracts with long-term care institutions for its I-SNP members, allow I-SNP clinical and care coordination staff access to I-SNP members who are institutionalized.
NCQA will review materials submitted by the organization that demonstrates that the organization’s contracts for I-SNP members allow I-SNP clinical and care coordination staff access to I-SNP Members who are institutionalized.
An institutionalized individual is defined in CFR § 422.2 as a special needs individual, and for the open enrollment period for institutionalized individuals at § 422.62(a)(4), an MA eligible individual who continuously resides or is expected to continuously reside for 90 days or longer in one of the following long-term care facility settings:
(1) Skilled nursing facility (SNF) as defined in section 1819 of the Act (Medicare).
(2) Nursing facility (NF) as defined in section 1919 of the Act (Medicaid).
(3) Intermediate care facility for individuals with intellectual and developmental disabilities as defined in section 1905(d) of the Act.
(4) Psychiatric hospital or unit as defined in section 1861(f) of the Act.
(5) Rehabilitation hospital or unit as defined in section 1886(d)(1)(B) of the Act.
(6) Long-term care hospital as defined in section 1886(d)(1)(B) of the Act.
(7) Hospital which has an agreement under section 1883 of the Act (a swing-bed hospital).
(8) Subject to CMS approval, a facility that is not listed in paragraphs (1) through (7) of this definition but meets both of the following:
(i) Furnishes similar long-term, healthcare services that are covered under Medicare Part A, Medicare Part B, or Medicaid; and
(ii) Whose residents have similar needs and healthcare status as residents of one or more facilities listed in paragraphs (1) through (7) of this definition.
This new element is NA for C-SNP and D-SNP members.
HP 2025