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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5.29.2018 CM 05 May practices make the individualized care plan available via patient portal, or are they required to provide the document in writing?

Although the care plan can be made available via the patient portal, it is essential that all patients have access to the document. If patients are not registered for the portal, they will not have access. In those cases, practices should use an alternative method to provide the written care plan to patients to ensure that all patients have access after an appointment. Please note practices must document that the care plan is provided to the patient in the patient’s medical record.

PCMH 2017

5.29.2018 CC 04C Our PCPs and specialists use the same integrated EHR. Do we need to show tracking and follow-up?

Yes. Practices that use integrated systems must demonstrate how specialists are notified of a referral request and how the referral status will be tracked (including the specialist’s report). Even if the same EHR is used by both the primary care practitioner and the specialist, evidence must clearly demonstrate how the requirements are met within the system.

PCMH 2017

5.29.2018 CC 06 & CC 07 May a practice use credentialing information to meet CC 06 and CC 07?

No. Credentialing—although important to a clinician’s ability to practice—is not a specific indicator of performance or quality information. Practices must use performance data to evaluate the quality of specialists or consultants to whom they send patients. Performance data can be qualitative or quantitative and may be gathered from external reporting sources (e.g., PCSP recognition, CMS public reporting) or may be internal based on criteria defined by the practice (e.g., evaluating a specialist’s timeliness in returning referral reports, evaluating whether patients had a positive experience).

PCMH 2017

5.29.2018 QI 04A How many patients are practices required to survey?

NCQA does not prescribe a sample size or frequency of surveying; however, the survey must represent the entire patient population and not focus on specific conditions or patient groups

PCMH 2017

5.29.2018 CC 08 What is an example of an informal agreement?

An informal agreement could be a few sentences in a referral form, e-mail or other method of communication containing expectations for the specialist, including, but not limited to, the time frame for reporting to the primary care physician and specifying lab or test results that should be included in the report. This information is essential to clarify the relationship between the primary care provider and specialist.

PCMH 2017

5.29.2018 CC 12 How do practices document co-management arrangements?

The practice must demonstrate at least three examples demonstrating co-management arrangements, such as de-identified referral forms that include the arrangements or sections of the medical record specifying the clinician responsible for each component of care. For example, for a diabetic patient who is referred to a medical oncologist, the arrangement would identify which clinician manages the diabetes and which clinician manages the side-effects of the oncology treatment and their expectation for timely sharing of patient information.

PCMH 2017

5.29.2018 CC 14 Are practices required to show they can identify all patients who have been admitted to the hospital and treated in the ED?

No. Practices are not required to identify all patients admitted to the hospital or ED, but they must have a process for identifying patients admitted to facilities used most often by their population. In addition to a documented process, practices must also submit a log or report demonstrating that patients were identified.

PCMH 2017

5.29.2018 CC 21C How do practices demonstrate capability for electronic exchange of key clinical information with facilities?

There must be interconnectivity between the practice and facilities to exchange clinical information. The practice can demonstrate CC 21C via demonstration of the capability of the certified EHR to exchange clinical information.

PCMH 2017

5.29.2018 CC 14 Do hospitalization and ED visit data from the health plan meet the requirements of this criterion?

A practice may use health plan data to identify patients if it is provided at least weekly and if at least 75 percent of the patient population is represented by the health plan. The practice may use data from more than one health plan as long as the plans collectively represent at least 75 percent of the practice population.

PCMH 2017

5.29.2018 QI 06 Are practices required to use an NCQA-Certified survey vendor to administer CAHPS PCMH?

No, practices are not required to use an NCQA-Certified survey vendor.

PCMH 2017

5.29.2018 CC 08 Our practice is part of an integrated health system. Do we need to show agreements between primary care providers and specialists?

Yes. Practices must have an agreement or documented process outlining the responsibilities of the referring provider and the specialist, even in an integrated system. It is essential that each provider understands the expectations and responsibilities of the referral, including the frequency and methods of communication.

PCMH 2017

5.29.2018 CM 04 Does a clinical summary meet the requirement for a “plan of care”?

If the clinical summary also includes the details of the patient’s care plan (i.e., information outlined in the criterion guidance), then it would meet the requirement. A clinical summary alone that does not include the patient’s care plan information would not meet the requirement.

PCMH 2017