FAQ Directory

No. Verification of sanctions and exclusions are not product line–specific requirements. For each practitioner in the scope of credentialing, the organization must verify Medicare and Medicaid sanctions regardless of the product line for which practitioners are contracted.

HP 2025

Example: During a new-patient office visit, the patient reports receiving a colonoscopy in the previous year to their primary care provider. During the discussion, the provider documents the details (when and where the procedure occurred, findings) in the office visit progress notes in the patient’s EHR.

This example represents the intent behind the HEDIS guidelines because:

• The provider collecting the information has the appropriate clinical experience to interpret what the patient is sharing and assumes clinical accountability for that aspect of the patient’s clinical care.
• The provider documents the colonoscopy in the patient’s medical record allowing it to be accessible to other care team providers and to the member for clinical decision making.

HEDIS 2025

HEDIS Volume 2 provides guidance in several places:

• Member-reported services and biometric values general guideline.
  This general guideline states that member-reported services may be used only if collected by a primary care practitioner or specialist (if the specialist is providing a primary care service related to the condition being assessed, in the course of taking a member’s history), and if the information is included in the member’s health record.
• Supplemental data general guideline.
  Information on services reported by members often reside in non-standard supplemental sources. The supplemental data general guideline states that there must be evidence of provider accountability for the information documented. The guideline also states that documentation of member-reported services must be complete (e.g., date, place of service, procedure, prescription, test result or finding, practitioner type).
• Electronic Clinical Data Systems general guidelines.
  Organizations may develop workflows that result in documentation of member-reported services. A common example is documentation in systems identified as case management. The ECDS general guideline states that case management systems are shared, meaning that there is bidirectional access to the data. These data would be accessible to members and to members’ care teams for care coordination and planning.

HEDIS 2025

For Health Plan Accreditation 2025, the organization is only required to take action on one measure for Health Plan Ratings for which it received a 0 or 1 for QI 3, Element C, and one measure required for QRS in QI 3, Element D. However, if the organization chooses to address more than one measure in its improvement plan, the guidance regarding using one action to address all measures applies but NCQA will only score taking action on one measure for the 2025 standards year.

HP 2025

For commercial, Medicare and Medicaid organizations to be able to calculate an average rating for QI 3, Element B, they must receive a Health Plan Ratings scoresheet. Only organizations that have complete data receive a rating and scoresheet. Therefore, organizations that do not receive an HPR scoresheet will be scored NA in QI 3, Elements B and C. 

The organization must demonstrate that it meets the requirements in QI 3, Element A, and will not be eligible for NA for that element.

Similarly, if an Exchange organization either does not report QRS data to CMS or receives NR for the Exchange product line because it does not have a valid rate for any required QRS measure in Element D, it must demonstrate data exchange in QI 3, Element A.   

HP 2025

NCQA makes disaster accommodations on a case-by-case basis during the accreditation survey process.

The organization must document the events from the disaster that prohibited your organization from meeting the standard/element. During the accreditation survey, the surveyor will document all findings which will be reviewed by our Review Oversight Committee (ROC) to determine if any accommodations or exceptions should be granted.

The organization should communicate with the assigned ASC if accommodations are requested.

HEA 2025

The Colorectal Cancer Screening (COL-E) measure is based on the US Preventive Services Task Force (USPSTF) guidelines for colorectal cancer screening. The guidelines do not recommend serum (blood) testing (e.g., blood-based biomarker) and for this reason it does not meet criteria for the HEDIS measure. NCQA continually monitors clinical practice guidelines as they are updated.

HEDIS 2025

Yes. Organizations may not use PCS responses that are over 3 years old. If your question relates directly to a measure specification or general guideline that was revised from a previous measurement year, submit the question rather than using the answer in PCS.

HEDIS 2025

Only the LTI flag in the Monthly Membership Detail Data File may be used when identifying this exclusion. No other data sources may be used.

HEDIS 2025

Yes. Organizations may use the same sample for all measures, the same sample for two measures and a different sample for the third measure, or different samples for the three diabetes measures (GSD, EED, BPD).

HEDIS 2024

No. Organizations are still required to monitor for system controls. The NA for the system controls policies and procedures requirement (e.g., UM 12, Element A, factor 7, in Health Plan Accreditation) does not affect an organization’s ability to meet the corresponding system controls monitoring requirement (e.g., UM 12, Element B in Health Plan Accreditation); it means the organization is not required to describe the monitoring process in its policies and procedures, but must monitor that its systems are protecting data from unauthorized modifications. Also, as noted in “Related information” in the monitoring requirements (e.g., UM 12, Element B in Health Plan Accreditation), NCQA only reviews specific components for monitoring (e.g., for UM, NCQA reviews that the organization monitored receipt and notification dates).

Note: The referenced memo is on the NCQA website at https://www.ncqa.org/wp-content/uploads/2025-Retroactive-Changes-Memo_Final.pdf. It applies to the 2024/2025 standards year only; no exceptions (NA scores or other changes) will be made for the 2023 or prior standards years. Surveys conducted on standards prior to 2024 standards will be reviewed and scored accordingly; any corrective actions issued prior to the 2024 standards still apply

HP 2024

The OMB is requiring “Middle Eastern or North African” for the race/ethnicity combination list. If you do not have “Middle Eastern or North African” as a race only option (if you are collecting race and ethnicity separately), it is ok.

We are instructing practices to work with their vendor to include the “Middle Eastern or North African” option to the combination race/ethnicity category so practices can transition to the OMB race/ethnicity combo for future collection.
 

PCMH