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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8.15.2012 UPDATED: Completely overturned denials excluded from file review Are overturned denials excluded from file review for only UM 9, Elements C and D, or from all elements in UM 9?

Files submitted on or after November 1, 2012, are not included in file review for any element in UM 9.

8.15.2012 Evaluation Options: HEDIS Reporting and Scoring Are HEDIS/CAHPS measures reported during the third annual HEDIS reporting cycle scored for the First Evaluation Option?

8.15.2012 Evaluation Options: Status and Scoring How are plans scored that do not report HEDIS/CAHPS?

Standards-only accreditation scoring is based on 50 points.

8.15.2012 Evaluation Options: Status and Scoring Will currently accredited plans be scored 50 points for HEDIS/CAHPS and 50 points for standards?

No. Recalculation of accreditation scores is generally made against the HEDIS measures and point values in place at the time of the organizations last Full Survey.

8.15.2012 Evaluation Options: Accreditation Surveys May plans decline the accreditation status earned for a Full Survey?

Yes. A plan surveyed under the First Evaluation Option may decline the accreditation status (without penalty) at the completion of the survey, within 30 calendar days from receipt of its results. A plan that declines its accreditation status has the option to undergo a Follow-Up Survey within 12 months of receipt of its Full Survey results.

8.15.2012 Evaluation Options: Accreditation Surveys How soon will plans be able to earn accreditation for their Exchange product line?

NCQA-Accredited plans can earn accreditation for their Exchange product line as early as February 2013. Plans without previous NCQA Accreditation can apply for the Interim Evaluation Option as early as September 2012 and have their Exchange product line accredited as early as October 2013.

8.15.2012 Evaluation Options: Accreditation Surveys What is the Resurvey timeline for plans that score less than 85 percent of the possible points during the First Evaluation Option or the Renewal Evaluation Option?

A plan that scores less than 85 percent of the possible standards points must undergo a Resurvey within 12 months of the accreditation decision. The Resurvey look-back period is six months.

8.15.2012 Evaluation Options: Status and Scoring Is it possible for plans to score higher than Accredited status during any First Evaluation Option years?

Yes. Plans that notify NCQA that they want to be scored on HEDIS/CAHPS measures by December 31 (before the June HEDIS reporting date) may score higher than Accredited status.

8.15.2012 Evaluation Options: HEDIS Reporting and Scoring Will NCQA review and score HEDIS/CAHPS measures if a plan submits them for the Interim Evaluation Option?

No. HEDIS/CAHPS results will not be used to evaluate plans seeking accreditation through the Interim Evaluation Option.

8.15.2012 Evaluation Options: HEDIS Reporting and Scoring How does NCQA differentiate among plans that are accredited through the Renewal Evaluation Option and plans that are accredited through the First Evaluation Option but do not report HEDIS/CAHPS measures?

Plans that do not report HEDIS/CAHPS are capped at Accredited status. The list of plans that report HEDIS/CAHPS (or do not report) is available on NCQAs publicly reported Health Plan Report Card.

8.15.2012 Evaluation Options: Survey Process Will NCQA conduct onsite surveys (at the health plan) for the Interim Evaluation Option?

No. NCQA conducts onsite surveys for the First and Renewal Evaluation Options, but not for the Interim Evaluation Option.

8.15.2012 Evaluation Options: Standards and Guidelines CR 7: Recredentialing Verification was eliminated for Accreditation 2013. Is there a recredentialing requirement?

Yes. Verification requirements from CR 7 were merged into CR 3, Elements A_C.