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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8.15.2025 Executive Orders and NA Scoring Do organizations need to provide evidence about sexual orientation for HE 6, Element B, factor 3?

No. Organizations should not provide any documentation for HE 6, Element B, factor 3. The entire factor 3 requirement is NA for all surveys through June 30, 2026

HEA 2024

8.15.2025 UM Information Integrity Audit File Universe The denial and appeal Information Integrity audit universe specifies decisions (based on the notification date) made during the look-back period. Does the audit include data (decision notifications) from outside the look-back period?

Yes. When an organization conducts its UM Information Integrity audit, the audit universe includes data from the most recent 12 months from the timing of the audit. So, although the audit occurs within the look-back period, data reviewed may  include decision notification files from outside the formal look-back window, depending on timing. 

HP 2026

8.15.2025 Prioritizing Case Management Goals Can multiple case management goals be assigned the same priority level, such as “high”?

Yes, multiple goals can be assigned the same priority level (e.g., “high”), but the organization must still clarify the relative importance of each goal within the same assigned level. The intent of prioritization is to show how goals compare to one another in terms of urgency or importance.

For example, if three goals are all marked “high,” the organization must indicate which of those is the highest priority, second highest, and so on.

This applies to:
HPA: PHM 5, Element E
MBHO: QI 8, Element I
CM: CM 4, Element B
CM-LTSS: LTSS 3, Element C

CM 2026

8.12.2025 What is the role of a consultant during a virtual review or audit?

Unless a regular operational employee of the organization, a consultant is not to assume responsibility for generating or demonstrating the evidence for Recognition. While external consultants are welcome to be part of the virtual reviews or audit, these calls are led by the appropriate practice team members.  NCQA reserves the right to obtain contact information of consultants working with the practice as well as verify the identity of individuals present during the virtual review or audit.

PCMH

8.12.2025 What do we do if a practice has to close temporarily or permanently?

Any structural or operational change must be reported to NCQA. Organizations must contact their NCQA Representative for further instructions within 30 days of the change.

PCMH

8.12.2025 Which clinicians need to be listed in Q-PASS?

Every qualifying clinician at a practice site is required to be listed in Q-PASS. Clinicians who meet the following three criteria must be listed for each Recognized PCMH site they practice at:

  1. MDs, DOs, PAs and APRNs (including nurse practitioners and clinical nurse specialists) who practice internal medicine, family medicine or pediatrics.
  2. The clinician can be selected by patients as their primary care clinician. 
  3. The clinician has their own or shares a patient panel.

PCMH

7.15.2025 Acceptable Titles for Reviewers The explanation for UM 9, Element D, factor 5 specifies that the reviewer's title is their position or role in the organization. How does the organization document this for external reviewers?

If a reviewer is external to the organization, the title/role must reflect it (e.g., “External Reviewer,” “External Independent Reviewer”). 

HP 2025

7.15.2025 Licensure Compact Arrangements Does NCQA require clinicians to be licensed in every state where they provide services to patients?

Yes. Applicable clinical staff must be licensed and verified in all states where they provide care to members. 

A licensure compact arrangement between states is acceptable if the clinician’s licensure was primary source verified in the clinician’s home state. NCQA reviews the compact agreement for evidence that the state (or states) accepts the home state’s license in lieu of state licensure. 

CM 2020

7.15.2025 Obtaining Sanction and Exclusion information from the State Agency Some State Medicaid agencies do not provide both sanction and exclusion information. What does NCQA expect in this situation?

The organization must provide documentation from the agency confirming that it does not provide sanction/exclusion information. If the state agency declines to supply written confirmation, the organization documents its effort to obtain the information.  

The organization must verify Medicaid sanctions and exclusions from one of the additional sources specified in the standards and guidelines. The credentialing file must include evidence of both the unavailability of the information from the state agency and verification from an approved additional source. 

Applicable Standards: 

HPA: CR 3, Element B; CR 5, Element A 

CRPN: CRA 4, Element B; CRA 5, Element A; CRC 9, Element A; CRC 12, Elements B and C 

MBHO: CR 3, Element B; CR 5, Element A 

HP 2025

7.15.2025 Deduplication of Mammography Episodes on the Same Date of Service for Documented Assessment After Mammogram (DBM-E) If there is more than one eligible mammography episode on the same date of service, does that count as a single denominator event?

It is up to the organization to ensure that multiple mammograph episodes are the same event if they occur on the same date of service. HEDIS measure certification assumes events on the same day are different mammograms. If evidence shows the mammography episodes are the same, count only one. Organizations should develop their own methods and apply them consistently when reporting.

HEDIS 2025

7.15.2025 Multiple BIRADS assessments for Follow-Up After Abnormal Mammogram Assessment (FMA-E) Can one follow-up event meet criteria for multiple BIRADS assessments?

Yes. One follow-up event may meet criteria for multiple BIRADS assessments. Each BIRADS assessment counts as separate denominator events, and requires the appropriate follow-up to count toward the numerator. However, one breast biopsy may meet criteria for multiple high-risk BIRADS assessments, and one mammogram or ultrasound may meet criteria for multiple inconclusive BIRADS assessments.

HEDIS 2025

7.15.2025 Multiple BIRADS Assessments for Documented Assessment After Mammogram (DBM-E) If multiple distinct mammograms are identified on the same date of service, does a single BI-RADS score within 14 days of each mammogram make the member compliant for all mammograms?

No. Each mammogram requires a unique BIRADS assessment (e.g., two mammograms need two separate BIRADS to meet numerator criteria). A single documented BIRADS assessment dated on or within 14 days (15 days total) of multiple mammography episodes does not meet criteria for multiple denominator events.

DBM-E sample and test decks have been updated and re-posted. If you already received a status of “pass” for a DBM-E test deck, the status has been re-set and you must run the updated deck to certify. The deadline to certify the measure will be extended to July 31 so organizations can accommodate this update.

HEDIS 2025