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.

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7.17.2023 CVO: Use of software to collect credentialing information (API) May an organization use an application program interface (API) that retrieves data directly from a primary or approved source, even though it is not a web crawler?

Yes. Organizations may use an API to access data from a primary or approved source, and must provide documentation that the API collects information only from primary or approved sources.

Organizations that use an API must still meet the “Appropriate documentation” requirements in CVO 1, Element A, including documentation that the organization's staff reviewed the information.

As noted in an FAQ from February 15, 2023, use of another entity’s software to collect credentialing information is not considered delegation unless the entity also reviews the information on the organization’s behalf.

CVO 2022

7.17.2023 UM 5, Elements A-C: Notifying the Practitioner If an organization receives a request from a provider rather than a practitioner (for example, a lab or DME company), may the organization address the UM denial notification to the provider without also notifying the attending or treating practitioner as well?

No. Only addressing the UM denial notification to the provider does not meet the intent of the requirement. The UM denial notification must also be addressed to the attending/treating practitioner.

If information on the attending/treating practitioner was not provided with the request, the organization attempts to identify the practitioner and documents its efforts to identify the practitioner. If the organization is not able to obtain the name of the attending/treating practitioner, the practitioner’s name is not required. In such a case, the organization must address the notification "To the Attention of the Attending/Treating Practitioner.”

For urgent concurrent decisions, the organization may inform the hospital Utilization Review department staff without attempting to identify the attending/treating practitioner, with the understanding that staff will inform the practitioner.

In all cases, if the practitioner is not known, the organization must address the notification “To the Attention of the Attending/Treating Practitioner”; the practitioner’s name is not required.

UM-CR-PN 2023

7.17.2023 UM 5, Element A: Notifying the Practitioner If an organization receives a request from a provider rather than a practitioner (for example, a lab or DME company), may the organization address the UM denial notification to the provider without also notifying the attending or treating practitioner as well?

No. Only addressing the UM denial notification to the provider does not meet the intent of the requirement. The UM denial notification must also be addressed to the attending/treating practitioner.

If information on the attending/treating practitioner was not provided with the request, the organization attempts to identify the practitioner and documents its efforts to identify the practitioner. If the organization is not able to obtain the name of the attending/treating practitioner, the practitioner’s name is not required. In such a case, the organization must address the notification "To the Attention of the Attending/Treating Practitioner.”

For urgent concurrent decisions, the organization may inform the hospital Utilization Review department staff without attempting to identify the attending/treating practitioner, with the understanding that staff will inform the practitioner.

In all cases, if the practitioner is not known, the organization must address the notification “To the Attention of the Attending/Treating Practitioner”; the practitioner’s name is not required.

MBHO 2023

7.17.2023 Use of software to collect credentialing information (API) May an organization use an application program interface (API) that retrieves data directly from a primary or approved source, even though it is not a web crawler?

Yes. Organizations may use an API to access data from a primary or approved source, and must provide documentation that the API collects information only from primary or approved sources.

Organizations that use an API must still meet the “Appropriate documentation” requirements in CR 1, Element A, including documentation that the organization's staff reviewed the information.

As noted in an FAQ from February 15, 2023, use of another entity’s software to collect credentialing information is not considered delegation unless the entity also reviews the information on the organization’s behalf.

UM-CR-PN 2023

6.23.2023 July 2023 PCSP Summary of Updates What changes were made to the PCSP Standards and Guidelines for Version 6?

TopicUpdate Highlights
Front Matter (Audit Section)Evidence of implementation submitted for an audit, including reporting data, must be recent to the time of the audit.
Front MatterAdded a section addressing conflicts with regulatory requirements. This applies to all Recognition products.
CM 04Added: “The care plan needs to be written in a health literacy level accessible to the patient (not medical jargon or billing codes).”

Also added – “Note: After-visit summaries may only be used if it contains plain language and shows patient involvement in the creation of the plan.”

KM 06Removed “pronouns” and added “language” in the guidance section as examples that may not be submitted for “other aspects of health”.
KM 09
 		Added clarification on evidence: “Practices are to submit a report that is broken down by numerator/denominator and percentages for each category. For example, Black or African American = 400/1000 (40%); Asian = 300/1000 (30%), etc.”
PM 20New criterion – Person-Driven Outcomes Approach: Monitoring and Follow-Up

PCSP 2019

6.23.2023 July 2023 PCMH Summary of Updates What changes were made to the PCMH Standards and Guidelines for Version 9?

TopicUpdate Highlights
Front Matter (Audit Section)Added “Evidence of implementation submitted for an audit, including reporting data, must be recent to the time of the audit.”
Front MatterAdded a section addressing conflicts with regulatory requirements. This applies to all Recognition products.
CM 04Added: “Note: After-visit summaries may only be used if they contain plain language and show patient involvement in the plan’s creation.”

Also added, “The care plan is written at a health literacy level accessible to the patient (i.e., does not contain medical jargon, abbreviations/acronyms or billing codes).”

KM 09Removed “pronouns” and “language” in the guidance section as an example of “other aspects of health”.
KM 09Added a clarification about evidence, “Practices are to submit a report that is broken down by numerator/denominator and percentages for each category. For example, Black or African American = 400/1000 (40%); Asian = 300/1000 (30%), etc."
AC 01Added to the guidance: The key to this criterion is patient preference. Some examples of questions asked may include, but are not limited to:
• Our practice is considering extended hours to 7PM. What day of the week would you most prefer?
• Our practice offers same day appointments at 9AM each day. Does this time work for your same day needs? Yes/No with a follow-up question: If not, please identify a time that you prefer.
• If scheduled telehealth visits were offered, would you use them instead of an in-person office visit? (Y/N or Likert Scale). Can follow-up with options.
CM 11New criterion – Person-Driven Outcomes Approach: Monitoring and Follow-Up
QI 01 and 02Clarified that beginning in 2024, standardized measures must be used and reporting through the Measures Reporting Tile in Q-PASS.

PCMH 2017

6.15.2023 Use of Delegate's Self-Service Portal for Delegation Reporting Is it acceptable for organizations to pull reports from a delegate’s system for the delegation agreement reporting requirement?

Yes, if the delegation agreement addresses the required information in the Explanation (e.g., CR 8, Element A, factor 3 for credentialing). The delegation agreement must specify:

  • How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
  • What information is reported by the delegate in the delegate's system about the delegated activities.
  • How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).

UM-CR-PN 2023

6.15.2023 Use of a Delegate's Self-Service Portal for Delegation Reporting Is it acceptable for organizations to pull reports from a delegate’s system for the delegation agreement reporting requirement?

Yes, if the delegation agreement addresses the required information in the Explanation. The delegation agreement must specify:

  • How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
  • What information is reported by the delegate in the delegate's system about the delegated activities.
  • How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).

WHP 2019

5.15.2023 Colorectal Cancer Screening (COL-E) Should the Colorectal Cancer Screening-E (COL-E) age stratification be updated?

Yes. Replace the reference to “46-49” with “46-50,” and replace the reference to “50-75” with “51-75” in the age stratification and in Table COL-E-A-4: Data Elements for Colorectal Cancer Screening.

Exchange 2023

5.15.2023 Social Need Screening and Intervention (SNS-E) Should the SNS-E measure include exclusion criteria for Medicare members?

No. There are no Medicare member exclusions. Remove the second bullet from Exclusion 1, which reads:

  • Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
    • Enrolled in an Institutional SNP (I-SNP) any time during the measurement period.
    • Living long-term in an institution any time during the measurement period, as identified by the LTI flag in the Monthly Membership Detail Data File. Use the run date of the file to determine if a member had an LTI flag during the measurement period.

Exchange 2023

5.15.2023 Definition of Annual Does NCQA’s definition of “annual” allow for a 2-month grace period?

As noted in the Glossary appendix, NCQA’s long-standing definition of “annual” is 12 months plus a 2-month grace period (12–14 months). “Grace period” refers to allowing organizations to complete an activity after it is due and not before it is due.

CM-LTSS 2023

5.15.2023 Applicable Standards for Mail Service Organizations Considered Delegates What standards are considered a delegation relationship if an organization uses a mail service organization to meet the distribution requirements?

NCQA considers the following standards to be a delegation relationship if an organization uses a mail service organization to meet the distribution requirements:

  • NET 4, Element A: Notification of Termination
  • NET 4, Element B: Continued Access to Practitioners
  • UM 5, Elements A, B, C: Timeliness of UM Decisions
  • UM 7, Elements B, C, E, F, H, I: Denial Notices
  • UM 9, Elements B, D: Appropriate Handling of Appeals
  • UM 11, Element B: Pharmaceutical Restrictions/Preferences
  • UM 11, Element C: Pharmaceutical Patient Safety Issues

UM-CR-PN 2023