FAQ Directory

If an organization does not have evidence that, during the look-back period, it assisted members transition to care when their benefits were exhausted (QI 3, Element E), NCQA reviews the organization’s policies and procedures in place throughout the look-back period.

In addition to the policies and procedures, the organization must provide documentation (e.g., attestation) indicating that there were no such instances during the look-back period. 

HP 2025

In the 2024 Health Plan Ratings, Follow-Up After High Intensity Care for Substance Use Disorder (FUI) was removed from the final ratings for the Medicare product line due to insufficient data in MY 2023 HEDIS submissions.

If a measure is not required in the 2024 Health Plan Ratings, it is not required in QI 3. Thus, because FUI was not included in the most recent scoresheet for the Medicare product line, it   is not included in the average calculation in Element B and will not be considered (may not be chosen as a measure to act on) in Element C.

HP 2025

Yes. The training requirement is new and was not included in the systems controls requirement. The organization must update its delegation agreement to include delegation of UM and CR information integrity training.

The organization may add an addendum to include delegation of the new training requirement. The addendum must be mutually agreed on by the organization and the delegate.

HP 2025

No. For standards year 2025 only, NCQA will allow all organizations, regardless of their audit schedule, to submit a detailed implementation plan in lieu of conducting the delegation oversight information integrity audit.    

The implementation plan for each applicable delegate must include:

• The delegate’s name.
• The entity conducting the audit (organization or delegate).
  • If the delegate conducts the audit, the implementation plan must include the organization’s plan for review and evaluation of audit findings.
• The title of staff who conduct the audit.
• The audit methodology.
• The audit due date.

Organizations must submit either an information integrity audit report or an audit implementation plan (for selected delegates) at the time of survey submission for the following products:

• HP: UM 13, Element C, factors 5-7; CR 9, Element C, factors 5-7.
• CRPN: CR 3, Element C, factors 5-7.
• UMCRPN: UM 13, Element C, factors 5-7.
• MBHO: UM 12, Element C, factors 5-7; CR 9, Element C, factors 5-7. 

Organization-level information integrity audits must be conducted, and an implementation plan is not acceptable for the following requirements: 

• HP: UM 12, Element D; UM 12, Element F, CR 8, Element C.  
• CRPN: CR 2, Element C.
• UMCRPN: UM 12, Element D; UM 12, Element F.
• MBHO: UM 11, Element D; UM 11, Element F; CR 8, Element C.

Note: A related question was posted on 1/15/2025: “Do organizations need to conduct a delegation audit(s) on the 2025 Information Integrity standards within 12 months prior to survey submission date?” This FAQ replaces that post.

HP 2025

The changes made to the CCS/CCS-E continuous enrollment criteria for QRS MY 2024 was made in error. Use the following continuous enrollment criteria for MY 2024, which align with previous measurement years: 

CCS:

Continuous enrollment: The measurement year.

CCS-E:

The member was enrolled with a medical benefit throughout the participation period.

NCQA certified organizations were tested using the accurate continuous enrollment criteria.

Exchange 2024

No. NCQA will not adjust the look-back period. For verifications conducted before July 1, 2025, the organization or its delegate(s) can obtain information from any source in the factor requirement. Verifications conducted on or after July 1, 2025, must include the state Medicaid agency and one of the other listed sources.

This applies to:
CRPN: CRA 4, Element B, factor 2; CRC 12, Element B, factor 1.
MBHO: CR 5, Element A, factor 1.

HP 2025

Applications processed before July 1, 2025, will not be held to the factor 6 requirement and will be scored NA.

Applications processed on or after July 1, 2025, will be scored on the factor 6 requirement, but will not be held against the 6-month look-back period until surveys on or after January 1, 2026.

Note: CAQH is updating its credentialing application to include fields for race, ethnicity and language, and a statement regarding anti-discrimination. Updates are scheduled to go live on July 1, 2025.

This applies to:
HPA: CR 3, Element C, factor 6.
CRPN: CRA 3, Element A, factor 6; CRC 10, Element A, factor 6; CRC 11, Element A, factor 6.
MBHO: CR 3, Element C, factor 6.

HP 2025

Yes. During the audit in CR 8, Element C in HPA/MBHO (CR 2, Element C in CRPN), organizations must review all credentialing information in Element A associated with the selected practitioners’ files. This includes all credentialing verification information, credentialing committee minutes and ongoing monitoring reports.

HP 2025

HP 2025

HP 2025

Yes. The intent of LTSS 2, Element B in CM-LTSS (HE 2, Element F in HEA; LTSS 1, Element E in HPA) is that organizations have policies and procedures in place for managing access to and use of race/ethnicity and language data that cover all forms of media, devices and data storage.

CM-LTSS 2025

For CM 7, Element E, organizations must verify the license of clinical staff only in states where they provide services to patients.

CM 2020