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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5.22.2018 CM 01 What’s the difference between CM 01 and CM 03 as both look at identifying high risk patients?

CM 01 focuses on the practice’s established criteria and systematic process for identifying patients in need of care management. Comprehensive risk stratification in CM 03 requires a more complex identification process than that of CM 01. CM 03 goes beyond simply establishing criteria and provides elective credit to practices that are using a risk assessment process to identify patients for care management, leveraging clinical data about the patients; it is about stratifying patients using all the factors that put the patient at higher risk and in need of assistance in managing their health. If a practice meets CM 03, it will automatically meet CM 01.
 

This applies to the following Programs and Years:
PCMH 2017

5.22.2018 AC 07 Does a link to the practice’s Web page showing available practice activities meet the requirements for AC 07?

Documentation may be a screen shot demonstrating system capability. This could be multiple screenshots (one of the Web portal page and screenshots for each item) or one screenshot showing evidence of multiple capabilities required (requesting medication refills, appointments and requesting a referral or test) on an active website. Practices are also encouraged to demonstrate these capabilities with their evaluator during their virtual check-in.

This applies to the following Programs and Years:
PCMH 2017

5.22.2018 AC 11 Urgent care visits or visits during extended hours may not be available with a patient’s primary care clinician. Does NCQA require a particular percentage of visits must be with a selected primary care clinician?

No. NCQA does not prescribe a percentage, nor does it expect patients to be seen by their selected primary care clinician for a specific percentage of visits.
 

This applies to the following Programs and Years:
PCMH 2017

5.22.2018 AC 06 Our practice has a contract with a telehealth company that provides primary care to patients when they cannot come into the office. Does this meet the requirement for an alternative clinical encounter?

Yes, this meets the requirement if the telehealth provider is a clinician, provides a scheduled appointment and has access to practice systems and the patient’s medical record.

This applies to the following Programs and Years:
PCMH 2017

5.22.2018 AC 11 What does NCQA mean by a goal must be set? Are there specific parameters on what the goal must be?

The practice should set its own goal for continuity of patient visits with their selected primary care provider or care team and then monitor that percentage to evaluate its performance. The practice should set goals such as by percentage, number of visits, etc. for the frequency patients should be seeing their selected provider and then monitor to see how frequent they are meeting their goal. The practice should provide its report including the rate of visits for patients with their provider including the goal established.
 

This applies to the following Programs and Years:
PCMH 2017

5.22.2018 AC 10 How should residency clinics handle clinician selection?

Residency clinics should give patients the option to choose a care team that is under the direction of a staff or supervising physician. The personal clinician would not be a resident because the resident will no longer be associated with the clinic when their residency ends.
 

This applies to the following Programs and Years:
PCMH 2017

5.22.2018 AC 03 We are a hospital-owned practice; the ED serves as an after-hours clinic. Does this meet the requirements?

No. AC 03 requires practices to offer appointments outside regular business hours for both routine and urgent care. Using the ED for after-hours care does not meet the requirement since patients cannot schedule and access routine appointments at the ED.

This applies to the following Programs and Years:
PCMH 2017

5.22.2018 AC 08 How does NCQA define “timely” phone or e-mail clinical advice? Are practices required to document response time?

Practices define “timely” advice after considering the needs of their population. Practices must submit their written policy for responding to calls and e-mails, which may categorize the types of requests and appropriate response times.
Practices must also monitor and demonstrate their documented process defining response times to a nonurgent message and a report summarizing response times.
 

This applies to the following Programs and Years:
PCMH 2017

5.22.2018 AC 02 Are practices required to reserve separate same-day appointment slots for routine and urgent visits?

No. Practices must show appointment slots that are available for both urgent/acute and routine care, but may have a policy to accommodate patients with urgent/acute care needs first.

This applies to the following Programs and Years:
PCMH 2017

5.22.2018 AC 03 May practices refer patients to an associated urgent care site or facility for care outside regular business hours?

Yes. Practices may refer patients to associated urgent care sites or facilities (i.e., facilities with which the practice has a relationship or an agreement to work together) to meet AC 03, but must provide a documented process demonstrating how patients are referred to facilities for scheduled routine and urgent appointments. The facility must have access to patient medical records outside regular business hours.

This applies to the following Programs and Years:
PCMH 2017

5.22.2018 AC 02 Our clinic has walk-in appointments available every day. Do these count as same-day appointments?

No. Walk-in appointments are different from scheduled same-day appointments. Same-day appointments offer patients the opportunity to schedule a routine or urgent visit at a specific time to enable more patient-centered and convenient access; this prevents the need to wait for the next available clinician at the clinic.

This applies to the following Programs and Years:
PCMH 2017

5.22.2018 AC 02 Are practices required to measure their capacity to see patients or to measure the utilization of same-day appointments (i.e., number of patients seen)?

Practices are expected to show both availability (i.e., open appointment slots at the beginning of the day) and use of same-day appointments for a period of five consecutive days. Practices should also monitor the availability of same-day appointments against their documented process. Practices may use utilization of same-day appointment access as an indication of patient need.

This applies to the following Programs and Years:
PCMH 2017