Guidance for Corrective Action Plan (CAP) Surveys with a 6-Month Look-Back Period

In a CAP Survey, organizations must undergo file review to demonstrate evidence that the required CAP was implemented and adopted into normal business processes.  Following the final full survey Accreditation status report date:

  1. Within 30 days, organizations must submit their documented CAP which addresses all findings.
  2. Within 6 months, organizations must undergo CAP survey, scheduled by NCQA.

For CAP Surveys prior to September, organizations may select one of two options:

  1. Request that the CAP Survey be delayed until March 2021. This survey will be based on a look-back period of October 2020–March 2021. The organization’s current status, with CAP modifier, will remain until completion of the CAP Survey.
  2. Submit files from the applicable look-back period based on the submission date for the CAP Survey, including files from March–September 2020. File review will be based on all files available and normal file review rules will apply.

Surveyors will document and explain the organization’s failure to meet requirements due to COVID-19 for ROC review.

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