No. The requirement is that organizations verify Medicare sanctions from any of those sources, but there is no requirement to verify sanctions from all of them.
MBHO 2025
FAQ Directory
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1.15.2025 Sources for Medicare Sanctions (MBHO) Are organizations required to verify Medicare sanctions from all of the following sources?
• AMA Physician Master File.
• FSMB.
• NPDB.
• SAM.gov.
1.15.2025 Reviewer Names on Denial and Appeal Notifications (MBHO & UM) Does NCQA require names or signatures of the reviewers on UM denial and appeal notifications?
1.15.2025 Medication Lists deleted from the Asthma Medication Ration (AMR) measure A new version of the MY 2024 Medication List Directory (MLD) was released on 1/15/2025 with changes to asthma medications. What was the reason for the changes and how does this impact the Asthma Medication Ratio measure specification?
An error was identified in the HEDIS MY 2024 Medication List Directory (released on April 1, 2024). For the Asthma Medication Ratio (AMR) measure, “package size” and “unit” are required to perform calculations. If we cannot find package size and unit for NDC codes, we cannot include the codes in the AMR medication lists. For the MY 2024 Update release of the MLD, an alternative method was used to identify package size and unit so more codes could be included in the medication lists. Because this method resulted in incorrect information, we removed these codes from 11 medication lists.
- Albuterol Medications
- Asthma Controller and Reliever Medications
- Beclomethasone Medications
- Budesonide Formoterol Medications
- Budesonide Medications
- Ciclesonide Medications
- Fluticasone Medications
- Fluticasone Salmeterol Medications
- Formoterol Mometasone Medications
- Levalbuterol Medications
- Mometasone Medications
Three medication lists were removed from the AMR measure.
- Fluticasone Furoate Umeclidinium Vilanterol Medications
- Salmeterol Medications
- Tiotropium Medications
Customers who purchased the HEDIS MY 2024 Medication List Directory should re-download the file from the My Downloads section of their My NCQA account. Customers who purchased a product that contains the AMR measure specification should delete the three medication lists, consistent with how changes from the technical update are applied.
HEDIS 2024
1.15.2025 Use of documents produced using the Consolidated Clinical Document Architecture (C-CDA) standard Can documentation produced using the C-CDA standard, such as Continuity of Care Documents (CCD), discharge summaries or progress notes, be used as proof-of-service documentation or medical record review?
1.15.2025 NPDB: Acceptable Source for Medicare and Medicaid Exclusions (MBHO) Is the NPDB an acceptable source for Medicare and Medicaid exclusions?
Yes. The NPDB is an acceptable source for both Medicare and Medicaid exclusions.
For Medicaid, organizations must obtain exclusion information from the state Medicaid agency, in addition to either of the following sources:
NPDB, or
List of Excluded Individuals and Entities maintained by OIG and available over the internet).
For Medicare, organizations may obtain exclusion information from any of the NCQA acceptable sources.
MBHO 2025
12.16.2024 NPDB Acceptable Source for Medicare and Medicaid Exclusions Is the NPDB an acceptable source for Medicare and Medicaid exclusions?
For Medicare, organizations may obtain exclusion information from any of the NCQA acceptable sources. |
HP 2025
12.16.2024 Sources for Medicare Sanctions Are organizations required to verify Medicare sanctions from all of the following sources?
• AMA Physician Master File.
• FSMB.
• NPDB.
• SAM.gov.
12.16.2024 Reviewer Names on Denial and Appeal Notifications Does NCQA require names or signatures of the reviewers on UM denial and appeal notifications?
12.16.2024 MMP Plans CMS intends to dissolve Medicare-Medicaid Plan (MMP) contracts in 2026. Will that change product line rules for Accreditation?
12.13.2024 Advance Notice of RAND Table Changes for HEDIS MY 2025 How is NCQA changing the release of RAND numbers for HEDIS reporting beginning in MY 2025?
NCQA will remove the RAND table from the Guidelines for Calculations and Sampling with the release of the HEDIS MY 2025 Technical Update on March 31, 2025. Future releases of the HEDIS Volume 2: Technical Specifications for Health Plans publication will not contain a RAND table.
Beginning MY 2025, NCQA will use an alternative timeline and approach to distribute RAND numbers for HEDIS reporting. This information will be released in the NCQA store for purchasers of HEDIS Volume 2 in the November before production of systematic samples for hybrid reporting (e.g., November 2025, for MY 2025).
Organizations participating in NCQA’s Measure Certification program will receive separate guidance on how NCQA will accommodate this change for certification of systematic sampling logic.
HEDIS 2025
11.15.2024 Inconsistency with Member-Reported Services Requirements What are common themes in data containing member-reported services that suggest noncompliance with HEDIS requirements and should not be used?
Common themes include:
- Clinical accountability for the information.
An arrangement may exist where a provider, such as a PharmD, interacts with members to collect information on their last colorectal cancer screening or breast cancer screening. It is unclear if a PharmD has the appropriate clinical training to document the complete context of the service or interpret the information being shared. Nor is it evident that a PharmD would be clinically accountable for that aspect of the member’s care (preventive cancer care).
Another arrangement that may exist includes workflows where providers (e.g., NPs, PAs) contact a plan’s membership annually to assess a member’s medical history, including when they received their last cancer screenings. It is unclear if a singular touchpoint by the NP/PA indicates that the provider has clinical accountability for the member’s care. Organizations are not allowed to call members to collect data.
- Including and maintaining information in the health record.
A member’s health record should be accessible to the member and the care team responsible for that aspect of their care. Systems that are internal-facing only to a plan do not represent a source of data that contribute to an individual’s ongoing clinical care. Further, an individual’s health record should be available to them to reference or share with a care team in the future.
HEDIS 2025
11.15.2024 Implementation Plans for Health Equity Will the implementation plan deadlines be extended for the 2024 Health Equity Accreditation and Health Equity Accreditation Plus products?
Yes. For Initial Surveys scheduled on or between July 1, 2024, and June 30, 2026, the organization may submit a detailed implementation plan that includes a timeline as evidence for applicable factors.
Implementation plans may be submitted for Initial Surveys for the following requirements until June 30, 2026:
HE 2, Element A.
HE 2, Element D.
HE 2, Element E.
HE 2, Element G.
HE Plus 3, Element C.
HE Plus 5, Element B.
HE Plus 5, Element E.
HEA 2024