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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10.12.2018 QI 04B Can my practice use comments received in a social media format (i.e., Yelp, Facebook, etc.) as qualitative feedback for QI 04B?

Yes, collection of qualitative data through reviews on Google, Yelp, Facebook, Health Grades, etc. may be used as data for QI 04B if the practice actively notifies patients of the availability of those sites to submit patient experience information. If the sites are not actively advertised and not all patients are aware and represented, it would not meet the intent of the criteria.

PCMH 2017

10.12.2018 CM 05 If a practice offers to print a care plan for the patient but the patient declines, would this count as a 'Yes' or 'No' in the numerator.

If the practice offers to print the care plan and the patient declines, the practice may count the patient as a 'Yes'.

PCMH 2017

10.12.2018 Evidence Do documented processes need to be 90 days old to be submitted?

No, the redesigned PCMH process enables practices to enroll and transform into a PCMH over the course of a 12 month period. If the documented process has been implemented for a sufficient amount of time for the practice to demonstrate the needed evidence to meet criteria, the practice may submit it for review.

PCMH 2017

10.12.2018 AR-PH-1 (2018 Version) AR-KM 01 (2019 Version) Is it necessary to provide evidence in addition to affirming that we send out proactive reminders for all the necessary categories and noting the frequency?

No additional evidence is needed beyond answering the questions. Since all practices completing Annual Reporting have already shown detailed evidence previously during the transformation phase, Annual Reporting has reduced the administrative burden of maintaining recognition by reducing the amount of evidence that must be submitted.

PCMH 2017

10.12.2018 BH 15 & 16 What is the difference between BH 15 & BH 16 in the Behavioral Health Distinction program?

In BH 15 (Core), the practice monitors either a mental health condition OR a substance use disorder. BH 16 is elective because it raises the bar by evaluating whether practices monitor both a mental health condition AND a substance use disorder.

PCMH 2017

10.12.2018 AC 10 & 11 Does a single clinician practice need to provide a documented process and report for AC 10 and AC 11 as all patients would be on the same panel and always see their selected clinician by default?

No, a single clinician practice may simply attest to having a single clinician. This can be done using the text box option of Q-PASS to receive credit for these criteria.

PCMH 2017

10.12.2018 KM 07 For KM 07, should the required report outline what percentage of patients have a social determinant of health noted in the chart, or should the report include what the social determinants are and what percentage of patients fall under each?

Elective criterion KM 07 goes beyond providing the percentage of patients with social determinants of health documented in the medical record; the report should include the breakdown by social determinant(s) so the practice understands which social determinants impact their patients to better implement appropriate care interventions. The intent of elective criterion is for the practice to show how it monitors social determinants of health at the population level for its patient population and also how it uses that data to address and assist in overcoming those social determinants of health. Reports may be generated from data collected in KM 02 G.

PCMH 2017

9.15.2018 Data collection for prevention programs for behavioral healthcare for QI 6, Element A, factor 5 For QI 6, Element A, factor 5, are organizations required to have implemented a preventive behavioral healthcare program in order to meet the factor?

No. Element A does not require organizations to implement a preventive behavioral healthcare program. The intent of factor 5 is that organizations collect data to determine if there are behavioral health issues that could be prevented if a program were to be implemented. Organizations collect data to meet Element A. Identifying the opportunity for such a program and implementing it is applicable to Element B.

HP 2019

9.15.2018 Life-planning activities for Complex Case Management (CCM) Policies and Assessment Are organizations required to address life-planning activities at the first contact and start of the CCM initial assessment?

No. After consideration, NCQA removed the requirement for case managers to address life-planning activities at the start of the initial assessment (first contact). This FAQ replaces the previous FAQ issued on October 15, 2017 (which has been deleted) regarding first contact, and the workbook has been adjusted to accommodate the change.

HP 2019

9.15.2018 Terminated arrangements more than 90 calendar days before submission If an organization terminated an arrangement with an NCQA-Accredited/Certified/Recognized delegate more than 90 calendar days before it submitted the completed survey tool, is the organization eligible for automatic credit for the portion of the look-back period when activities were performed by the delegate?

Yes. For non-file review requirements, if the arrangement was terminated more than 90 calendar days before submission of the completed survey tool, the organization is eligible for automatic credit for the portion of the look-back period when the NCQA-Accredited/ Certified/Recognized delegate conducted activities. For file review requirements, automatic credit is applied if the delegate processed (or handled) the file, regardless of when the delegation arrangement was terminated.

HP 2019

9.15.2018 Terminated arrangements more than 90 calendar days before submission (CM and CMLTSS 2017) If an organization terminated an arrangement with an NCQA-Accredited/Certified/Recognized delegate more than 90 calendar days before it submitted the completed survey tool, is the organization eligible for automatic credit for the portion of the look-back period when activities were performed by the delegate?

CM 2017

9.15.2018 Revised Look-back Period for UM 7, Elements C, F, I (factors 2 and 3) In the 2019 HPA Standards and Guidelines, NCQA added a fifth bullet to the factor 2 Explanation and revised the factor 3 Explanation in UM 7, Elements C, F and I. Will NCQA give organizations a grace period for the added information in factors 2 and 3 of UM 7, Elements C, F and I?

The intent of the added language in factors 2 and 3 was to clarify the minimum information required for expedited appeals. NCQA recognizes these are new requirements, and for this reason, has added the following language to the scope of review:

Organizations must implement the changes in factors 2 and 3 for files processed on or after 11/1/18.

NCQA will post an update in December for the 2019 HP publication to reflect this change.

HP 2019