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.

Filter Results
  • Save
  • Email
  • Print
expand all

8.15.2012 Evaluation Options: Basics In what order do organizations progress through the Evaluation Options?

For the Interim Evaluation Option: Interim, to First, to Renewal.

For the First Evaluation Option: First to Renewal.

After a plan progresses to the Renewal Evaluation Option, all subsequent surveys will be for that Evaluation Option, unless the accreditation lapses for more than two years.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: Standards and Guidelines Several elements in the First Evaluation Option require annual evaluation, even though the Evaluation Option has a six-month look-back period for all other elements. How do plans meet this annual requirement?

NCQA will expand the look-back period if it is necessary for plans to demonstrate that performance requirements are met and to produce an adequate sample for file reviews. For annual requirements, plans must complete the activity at least once during the prior year.

This applies to the following Programs and Years:

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?

No, unless a plan opts for HEDIS/CAHPS scoring.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: Basics For which Evaluation Options are organizations eligible if their accreditation has expired?

A plan whose accreditation status has expired or has been withdrawn for less than two years is eligible for the Renewal Evaluation Option with a 24-month look-back period.

A plan whose accreditation expired more than two years ago is eligible for accreditation through the Interim Evaluation Option or First Evaluation Options with a six-month look-back period.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: HEDIS Reporting and Scoring When must plans report HEDIS/CAHPS measures if they are going through the First Evaluation Option?

Plans report HEDIS/CAHPS measures during the third annual HEDIS reporting cycle of their accreditation status. For example, if an organization receives a status in September 2014, it must submit audited HEDIS/CAHPS results in June 2017.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: Basics Which Evaluation Option should plans with New Health Plan accreditation apply for next?

Plans with NHP accreditation must apply for the Renewal Evaluation Option with a 12-month look-back period.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: HEDIS Reporting and Scoring Plans that are not scored on HEDIS/CAHPS are capped at Accredited status. Will NCQA grandfather plans that earned Commendable status but were not scored on HEDIS/CAHPS?

Yes. The Commendable status will remain valid until the plans existing accreditation status expires.

This applies to the following Programs and Years:

7.16.2012 Medical Record Review Validation Has NCQA communicated the changes to the MRRV process?

Yes. We sent communication to plans, auditors, vendors, physician groups, purchaser groups and state and federal agencies.

This applies to the following Programs and Years:
HEDIS 2013

7.16.2012 Initiation and Engagement of Alcohol and Other Drug DependenceTreatment In the Initiation of AOD Treatment indicator, the third paragraph states that if the Index Episode was an outpatient, intensive outpatient, partial hospitalization, detoxification or ED visit, the member must have an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization with an AOD diagnosis, within 14 days of the IESD (inclusive). What does "inclusive" mean?

"Inclusive" means the IESD is day 1 in the 14-day count for the Initiation of AOD Treatment indicator. The time frame for initiation is the IESD and the next 13 days, for a total of 14 days. For example, if a members IESD was an outpatient visit on August 1, the initiation visit must occur on or between August 1 through August 14.

This applies to the following Programs and Years:
HEDIS 2013

7.16.2012 Initiation and Engagement of Alcohol and Other Drug DependenceTreatment The Engagement of AOD Treatment indicator requires initiation of AOD treatment and two or more inpatient admissions, outpatient visits, intensive outpatient encounters or partial hospitalizations with any AOD diagnosis within 30 days AFTER the date of the Initiation encounter (inclusive). Does "inclusive" mean that the initiation visit is included when determining compliance for engagement? What does "after" mean?

"Inclusive" means that the initiation visit is included when determining compliance for the Engagement of AOD Treatment indicator; therefore, the initiation visit is day 1 in the 30-day count. "After" means that the two additional visits must occur after the date of the initiation encounter. For example, if a members initiation visit occurred on August 1, the engagement visits must occur on August 2 through August 30.

This applies to the following Programs and Years:
HEDIS 2013

7.16.2012 Medical Record Review Validation Have the criteria for determining a unique medical record process changed?

No. If the MRR processwhich includes training, tools, interrater reliability checks, rater-to-standard tests and any other quality control processis different by plan, product or product line, the auditor must conduct separate MRRV for each process by following the new validation steps.

This applies to the following Programs and Years:
HEDIS 2013