FAQ Directory

Yes, multiple goals can be assigned the same priority level (e.g., “high”), but the organization must still clarify the relative importance of each goal within the same assigned level. The intent of prioritization is to show how goals compare to one another in terms of urgency or importance.

For example, if three goals are all marked “high,” the organization must indicate which of those is the highest priority, second highest, and so on.

Update Notice:
This FAQ is being updated to clarify implementation expectations.
Organizations will have 90 days to implement the guidance outlined in this FAQ.
This means that organizations must adhere to the updated FAQ for surveys conducted on or after January 1, 2026.
Prior to January 1, 2026, organizations may continue to prioritize goals and reporting frequencies as they have in the past.

Applicable Standards:

HPA: PHM 5, Element E
MBHO: QI 8, Element I
CM: CM 4, Element B
CM-LTSS: LTSS 3, Element C

This applies to the following Programs and Years:

Although the “Prior Decision Date” field appears to be required, it does not apply to Credentialing Certification file reviews. For now, users should enter the same date used in the “Date Reported” (the date reported to the client) field. This is a temporary fix due to system limitations, and the field is expected to be removed by the end of 2025. Until then, using the same date ensures files can be completed successfully.

This applies to the following Programs and Years:

Under the 2025 standards and beyond, organizations must monitor adverse events for all practitioners. Limiting monitoring to primary care practitioners and high-volume behavioral healthcare practitioners is no longer acceptable.

This is a change from the 2024 standards.

Applicable Standards:
HPA: CR 5, Element A, factor 5.
MBHO: CR 5, Element A, factor 5.
CRPN: CRA 5, Element A, factor 5.

This applies to the following Programs and Years:

No. Organizations should not provide any documentation for HE 6, Element B, factor 3. The entire factor 3 requirement is NA for all surveys through June 30, 2026

This applies to the following Programs and Years:

Yes. When an organization conducts its UM Information Integrity audit, the audit universe includes data from the most recent 12 months from the timing of the audit. So, although the audit occurs within the look-back period, data reviewed may  include decision notification files from outside the formal look-back window, depending on timing. 

This applies to the following Programs and Years:

Unless a regular operational employee of the organization, a consultant is not to assume responsibility for generating or demonstrating the evidence for Recognition. While external consultants are welcome to be part of the virtual reviews or audit, these calls are led by the appropriate practice team members.  NCQA reserves the right to obtain contact information of consultants working with the practice as well as verify the identity of individuals present during the virtual review or audit.

This applies to the following Programs and Years:

Any structural or operational change must be reported to NCQA. Organizations must contact their NCQA Representative for further instructions within 30 days of the change.

This applies to the following Programs and Years:

Every qualifying clinician at a practice site is required to be listed in Q-PASS. Clinicians who meet the following three criteria must be listed for each Recognized PCMH site they practice at:

1. MDs, DOs, PAs and APRNs (including nurse practitioners and clinical nurse specialists) who practice internal medicine, family medicine or pediatrics.
2. The clinician can be selected by patients as their primary care clinician. 
3. The clinician has their own or shares a patient panel.

This applies to the following Programs and Years:

Yes. Applicable clinical staff must be licensed and verified in all states where they provide care to members. 

A licensure compact arrangement between states is acceptable if the clinician’s licensure was primary source verified in the clinician’s home state. NCQA reviews the compact agreement for evidence that the state (or states) accepts the home state’s license in lieu of state licensure. 

This applies to the following Programs and Years:

It is up to the organization to ensure that multiple mammograph episodes are the same event if they occur on the same date of service. HEDIS measure certification assumes events on the same day are different mammograms. If evidence shows the mammography episodes are the same, count only one. Organizations should develop their own methods and apply them consistently when reporting.

This applies to the following Programs and Years:

If a reviewer is external to the organization, the title/role must reflect it (e.g., “External Reviewer,” “External Independent Reviewer”). 

This applies to the following Programs and Years:

No. Each mammogram requires a unique BIRADS assessment (e.g., two mammograms need two separate BIRADS to meet numerator criteria). A single documented BIRADS assessment dated on or within 14 days (15 days total) of multiple mammography episodes does not meet criteria for multiple denominator events.

DBM-E sample and test decks have been updated and re-posted. If you already received a status of “pass” for a DBM-E test deck, the status has been re-set and you must run the updated deck to certify. The deadline to certify the measure will be extended to July 31 so organizations can accommodate this update.

This applies to the following Programs and Years: