FAQ Directory

Yes. If the HPV or Pap test sample source is vaginal, and can be billed to an appropriate code in the value sets, it may be used to meet criteria.

This applies to the following Programs and Years:

Yes, if the software uses the organization’s clinical criteria, policies and procedures and benefit package information, and the organization maintains control over the software implementation. Organizations may not use the software to make any denial decisions; those must be made by an appropriate clinical professional. Appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.

NCQA considers the use of external software to make approval decisions to be a vendor relationship for applicable requirements (e.g., UM 4, Element F). Refer to Appendix 3: Delegation and Automatic Credit Guidelines for additional information.

This applies to the following Programs and Years:

Yes. The following changes apply to SNP 2, Assessing and Coordinating Care.

NCQA added a new Element F, Contracts with Long-Term Care Institutions for I-SNP Members, that requires organizations to confirm that contracts with long-term care institutions for its I-SNP members, allow I-SNP clinical and care coordination staff access to I-SNP members who are institutionalized.

NCQA will review materials submitted by the organization that demonstrates that the organization’s contracts for I-SNP members allow I-SNP clinical and care coordination staff access to I-SNP Members who are institutionalized.

An institutionalized individual is defined in CFR § 422.2 as a special needs individual, and for the open enrollment period for institutionalized individuals at § 422.62(a)(4), an MA eligible individual who continuously resides or is expected to continuously reside for 90 days or longer in one of the following long-term care facility settings:

(1) Skilled nursing facility (SNF) as defined in section 1819 of the Act (Medicare).
(2) Nursing facility (NF) as defined in section 1919 of the Act (Medicaid).
(3) Intermediate care facility for individuals with intellectual and developmental disabilities as defined in section 1905(d) of the Act.
(4) Psychiatric hospital or unit as defined in section 1861(f) of the Act.
(5) Rehabilitation hospital or unit as defined in section 1886(d)(1)(B) of the Act.
(6) Long-term care hospital as defined in section 1886(d)(1)(B) of the Act.
(7) Hospital which has an agreement under section 1883 of the Act (a swing-bed hospital).
(8) Subject to CMS approval, a facility that is not listed in paragraphs (1) through (7) of this definition but meets both of the following:

(i) Furnishes similar long-term, healthcare services that are covered under Medicare Part A, Medicare Part B, or Medicaid; and
(ii) Whose residents have similar needs and healthcare status as residents of one or more facilities listed in paragraphs (1) through (7) of this definition.

This new element is NA for C-SNP and D-SNP members. 

This applies to the following Programs and Years:

In the 2024 Health Plan Ratings, Follow-Up After High Intensity Care for Substance Use Disorder (FUI) was removed from the final ratings for the Medicare product line due to insufficient data in MY 2023 HEDIS submissions.

If a measure is not required in the 2024 Health Plan Ratings, it is not required in QI 3. Thus, because FUI was not included in the most recent scoresheet for the Medicare product line, it   is not included in the average calculation in Element B and will not be considered (may not be chosen as a measure to act on) in Element C.

This applies to the following Programs and Years:

Yes. The training requirement is new and was not included in the systems controls requirement. The organization must update its delegation agreement to include delegation of UM and CR information integrity training.

The organization may add an addendum to include delegation of the new training requirement. The addendum must be mutually agreed on by the organization and the delegate.

This applies to the following Programs and Years:

No. For standards year 2025 only, NCQA will allow all organizations, regardless of their audit schedule, to submit a detailed implementation plan in lieu of conducting the delegation oversight information integrity audit.    

The implementation plan for each applicable delegate must include:

• The delegate’s name.
• The entity conducting the audit (organization or delegate).
  • If the delegate conducts the audit, the implementation plan must include the organization’s plan for review and evaluation of audit findings.
• The title of staff who conduct the audit.
• The audit methodology.
• The audit due date.

Organizations must submit either an information integrity audit report or an audit implementation plan (for selected delegates) at the time of survey submission for the following products:

• HP: UM 13, Element C, factors 5-7; CR 9, Element C, factors 5-7.
• CRPN: CR 3, Element C, factors 5-7.
• UMCRPN: UM 13, Element C, factors 5-7.
• MBHO: UM 12, Element C, factors 5-7; CR 9, Element C, factors 5-7. 

Organization-level information integrity audits must be conducted, and an implementation plan is not acceptable for the following requirements: 

• HP: UM 12, Element D; UM 12, Element F, CR 8, Element C.  
• CRPN: CR 2, Element C.
• UMCRPN: UM 12, Element D; UM 12, Element F.
• MBHO: UM 11, Element D; UM 11, Element F; CR 8, Element C.

Note: A related question was posted on 1/15/2025: “Do organizations need to conduct a delegation audit(s) on the 2025 Information Integrity standards within 12 months prior to survey submission date?” This FAQ replaces that post.

This applies to the following Programs and Years:

If an organization does not have evidence that, during the look-back period, it assisted members transition to care when their benefits were exhausted (QI 3, Element E), NCQA reviews the organization’s policies and procedures in place throughout the look-back period.

In addition to the policies and procedures, the organization must provide documentation (e.g., attestation) indicating that there were no such instances during the look-back period. 

This applies to the following Programs and Years:

The changes made to the CCS/CCS-E continuous enrollment criteria for QRS MY 2024 was made in error. Use the following continuous enrollment criteria for MY 2024, which align with previous measurement years: 

CCS:

Continuous enrollment: The measurement year.

CCS-E:

The member was enrolled with a medical benefit throughout the participation period.

NCQA certified organizations were tested using the accurate continuous enrollment criteria.

This applies to the following Programs and Years:

Applications processed before July 1, 2025, will not be held to the factor 6 requirement and will be scored NA.

Applications processed on or after July 1, 2025, will be scored on the factor 6 requirement, but will not be held against the 6-month look-back period until surveys on or after January 1, 2026.

Note: CAQH is updating its credentialing application to include fields for race, ethnicity and language, and a statement regarding anti-discrimination. Updates are scheduled to go live on July 1, 2025.

This applies to:
HPA: CR 3, Element C, factor 6.
CRPN: CRA 3, Element A, factor 6; CRC 10, Element A, factor 6; CRC 11, Element A, factor 6.
MBHO: CR 3, Element C, factor 6.

This applies to the following Programs and Years:

For CM 7, Element E, organizations must verify the license of clinical staff only in states where they provide services to patients.

This applies to the following Programs and Years:

This applies to the following Programs and Years:

Yes. During the audit in CR 8, Element C in HPA/MBHO (CR 2, Element C in CRPN), organizations must review all credentialing information in Element A associated with the selected practitioners’ files. This includes all credentialing verification information, credentialing committee minutes and ongoing monitoring reports.

This applies to the following Programs and Years: