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.
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 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?
5.22.2018 AC 13 Is it mandatory to use the American College of Family Physicians mentioned in the guidance for determining panel sizes?
5.22.2018 CM 01A Does tobacco use count as a behavioral health condition?
No. Tobacco use is an unhealthy behavior and is not considered a behavioral health condition. Practices need to identify behavioral health-related criteria pertinent to their specific patient population, which could include other (non-tobacco-related) substance use treatment, a behavioral health diagnosis, a positive screening result from a standardized behavioral health screener or psychiatric hospitalizations.
This applies to the following Programs and Years:
PCMH 20175.22.2018 AC 02 May practices block nurse practitioners’ schedules for same-day appointments?
Yes. Practices may use nonphysician members of the clinical care team, such as nurse practitioners or physician assistants (PA) who have their own panel of patients, for same-day appointments. There is no requirement for all clinicians to have same-day appointment slots available every day.
This applies to the following Programs and Years:
PCMH 20175.22.2018 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 20175.22.2018 AC 01 What are examples for how and where practices should collect data to address AC 01?
The intent of AC 01 is to assess the access needs and preferences of the practice’s patient population. To identify the best way to obtain this information, practices may need to review how they are currently collecting patient feedback on access needs. For example, a patient survey may ask patients if they are able to get an appointment when needed; however, that question doesn't tell you when patients want to access the practice. The practice may be offering access when the majority of patients don't or aren't able to utilize it.
Practices should collect and assess the feedback from patients to see if there's a need to adjust the access provided to patients. Some questions to consider include:
- What data are you already collecting on patient access (e.g. surveys, use of appointments)? Is it current and does it cover the whole patient population?
- How often do you need to assess the access needs of your patients?
- What variables may impact changes in the use of appointment types?
- If using patient satisfaction surveys, how many patients are actually responding? If the response rate is low, is there another mode of collecting feedback to get more input.
- Do the questions on your survey ask patients directly about their access needs or preferences?
This applies to the following Programs and Years:
PCMH 20175.22.2018 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 20175.22.2018 AC 12 Our practice offers night and weekend clinical advice coverage to patients through a phone service staffed by RNs. Does this meet the requirement for access to clinical advice?
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 20175.22.2018 AC 02 Are practices required to reserve separate same-day appointment slots for routine and urgent visits?
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.
