NCQA does not specify a time period required for remeasurement, but it must be long enough for the practice to implement a performance improvement plan and to assess results.
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 QI 12 When remeasuring to show improvement, what is an acceptable period of time between the initial measurement and the follow-up measurement period?
5.29.2018 CC 08 Are practices required to only refer to specialists with whom they have agreements, or is the requirement that an agreement be in place? Give an example of an agreement.
Practices are not restricted to referring patients only to practices with whom they have established agreements. NCQA reviews at least one example of a formal or informal agreement with a subset of specialists, but does not expect practices to have agreements with all specialists to whom they refer patients. The goal is that expectations are outlined in the agreement, in addition to expectations of timeliness/content of response from specialists.
This applies to the following Programs and Years:
PCMH 20175.29.2018 QI 12 How do practices assess the effectiveness of improvement actions?
Assessing effectiveness of improvement actions includes remeasurement to compare results over time and evaluation of what is driving change. Results may be quantitative (numerical data that demonstrate performance and can be compared to benchmarks) or qualitative (conceptual data that describe why performance is high or low), but practices must look at the goals set, actions taken to improve and previous or baseline results.
This applies to the following Programs and Years:
PCMH 20175.29.2018 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.
This applies to the following Programs and Years:
PCMH 20175.29.2018 CM 07 Are practices required to document that they assess and address patient barriers to meeting treatment goals?
Yes. Practices must assess whether there are barriers to meeting goals and should address any identified barriers. Both components must be listed in the medical record in order to select “Yes” in the Record Review Workbook. If the practice assesses potential barriers and none are identified, the practice may answer “Yes.”
Note: Practices must provide an example of how they meet each criterion and complete the Record Review Workbook. Examples are not required if a practice provides a report as evidence.
This applies to the following Programs and Years:
PCMH 20175.29.2018 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).
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 04C May practices use a “tickler file” for this item within CC 04?
No. The tracking system needs to include a record of both the order and receipt of results. A tickler system includes a copy of the order and is removed when results are received; it does not meet the requirement of the CC 04C because it does not maintain a record of receiving results.
This applies to the following Programs and Years:
PCMH 20175.29.2018 QI 04A How many patients are practices required to survey?
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.
This applies to the following Programs and Years:
PCMH 20175.29.2018 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.
This applies to the following Programs and Years:
PCMH 20175.29.2018 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.
