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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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
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
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
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
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
Best Practices from NCQA’s Virtual Primary Care Program to PCMH:
The following elective criteria were written during the creation process of the new Virtual Care program, but found to be best practice for all primary care settings. For this reason, nine new elective criteria are added to the PCMH program.
| Criteria | Criteria Title | Brief Description |
| TC 10 | Patient Consent | The organization requests patient consent to treatment through virtual modalities. |
| KM 30 | Prescribing Patterns | The organization tracks medication prescribing practices and performs analysis on prescribing patterns. |
| KM 31 | Interpreter Services | The organization uses competent interpreter or bilingual services to communicate with individuals in a language other than English. |
| KM 32 | Virtual Care Training | The organization provides staff training on relevant clinical and nonclinical topics. |
| AC 15 | Appropriate Modality of Care | The organization has a process for determining that virtual care is appropriate for the patient. |
| AC16 | Information for Appeals | The organization provides clinical information in response to appeals of denials based on medical necessity or treatment guidelines. |
| AC 17 | Services Covered by Insurance | The organization has a process for informing patients which services are covered by insurance. |
| QI 20 | Assessment of Clinician and Care Team Experience | The organization assesses clinician and care team experience for delivering care. |
| QI 21 | Goals and Actions to Improve Clinician and Care Team Experiences | The organization identifies at least one opportunity to improve the clinician and care team’s experience, implements an intervention and measures the intervention’s effectiveness. |
PCMH 2017
Cadence Thresholds Added:
Cadence thresholds are applied to 45 criteria to ensure continuous improvement and to avoid stagnation in workflows (i.e. “at least annually").
| Criteria Title |
| TC 06: Individual Patient Care Meetings/ Communication |
| TC 07: Staff Involvement in Quality Improvement |
| KM 02: Comprehensive Health Assessment |
| KM 03: Depression Screening |
| KM 04: Behavioral Health Screenings |
| KM 05: Oral Health Assessment |
| KM 06: Predominant Conditions |
| KM 07: Social Determinants of Health |
| KM 09: Diversity |
| KM 11: Population Needs B. Educates practice staff on health literacy and C. Educates practice staff in cultural competence. |
| KM 17: Medication Responses and Barriers |
| KM 21: Community Resource Needs |
| KM 23: Oral Health Education |
| KM 26: Community Resource List |
| KM 27: Community Resource Assessment |
| AC 01: Access Needs and Preferences |
| AC 09: Equity of Access |
| AC 11: Patient Visits with Clinician/Team |
| AC 13: Panel Size Review and Management |
| AC 14: External Panel Review and Reconciliation |
| CM 01: Identifying Patients for Care Management |
| CM 02: Monitoring Patients for Care Management |
| CM 03: Comprehensive Risk Stratification |
| CM 04: Person-Centered Care Plans |
| CM 05: Written Care Plans |
| CM 06: Patient Preferences and Goals |
| CM 07: Patient Barriers to Goals |
| CM 08: Self-Management Plan |
| CM 10: Person-Centered Outcomes Approach |
| CM 11: PCO: Monitoring and Follow-Up |
| CC 06: Commonly Used Specialists Identification |
| CC 07: Performance Information for Specialist Referrals |
| CC 14: Identifying Unplanned Hospital and ED Visits |
| QI 03: Appointment Availability Assessment |
| QI 04: Patient Experience Feedback |
| QI 05: Health Disparities Assessment |
| QI 07: Vulnerable Patient Feedback |
| QI 08: Goals and Actions to Improve Clinical Quality Measures |
| QI 09: Goals and Actions to Improve Resource Stewardship |
| QI 10: Goals and Actions to Improve Appointment Availability |
| QI 11: Goals and Actions to Improve Patient Experience |
| QI 13: Goals and Actions to Improve Disparities in Care/ Service |
| QI 15: Reporting Performance Within the Practice |
| QI 16: Reporting Performance Publicly or With Patients |
| QI 17: Patient/Family/ Caregiver Involvement in Quality Improvement |
PCMH 2017
| KM 02: Comprehensive Health Assessment | Added a note, "All patients need all the components addressed in their medical record. Providing components from multiple patients does not meet the intent." |
| KM 03: Depression Screening | Added this clarification in the adolescent section, "Screening under age 12 may be conducted as clinically indicated." |
| KM 14: Medication Reconciliation and KM 15: Medication Lists |
The thresholds have changed from more than 80% to more than 90%. |
| KM 26: Community Lists | Added, “The practice maintains a list of resources supported by the community and/or payers by selecting five topics or service areas of importance to the patient population.” |
| AC 01: Access Needs and Preferences | Added more detailed information, “The practice annually surveys patients to determine if existing access (e.g., days open, hours of operation, modalities, etc.) is meeting the needs of the patient population. The screening also collects input of the patient to understand their preferences.” |
| CM 04: Person-Centered Care Plans | Clarified that the required elements include the patient’s medication list and management as well as the patient’s comprehensive problem list. Also, provided more guidance on a care plan’s requirements. |
| CM 10: Person-Centered Outcomes Approach | Added, “If the organization chooses to use PROMs to track goals, NCQA recommends that the organization have at least 8–10 PROMs for clinicians to choose from, for use with patients.” |
| CC 04: Referral Management | Added, “The practice uses the patient's medical health history and clinical protocols to determine when a referral is necessary.” Also, “The organization confirms that referrals are local to the patient's community of residence, and whether the referral is in the patient's practitioner network.” Additionally, “The expectation is that the specialist/ancillary clinician return visit documentation so the loop can be closed” |
| CC 08: Specialist Referral Expectations And CC 09: Behavioral Health Referral Expectations |
Added, “The organization communicates referral expectations to patients, including the contact information of the referring clinician and additional instructions or education, if applicable.” |
| CC 21: External Electronic Exchange of Information | Added D. Clinical data exchange with payers. This is worth 1 elective credit point. |
| QI 01: Clinical Quality Measures and QI 02: Resource Stewardship Measures |
Added a documented process to the evidence. |
| Cadance Thresholds | Please see additional FAQ for cadence thresholds, added to 45 existing criteria. |
Criteria Retirement:
Eight criteria were identified as no longer serving a substantial purpose or adding meaningful value to primary care, leading to their retirement from the PCMH program.
| Criteria Identification and Title |
| TC 03: External PCMH Collaborations |
| TC 09: Medical Home Information |
| KM 08: Patient Materials |
| KM 18: Controlled Substance Review |
| KM 25: School/Intervention Agency Engagement |
| KM 28: Case Conferences |
| CC 12: Co-Management Arrangements |
| QI 18: Electronic Submission of Measures |
PCMH 2017
Yes. Organizations that choose to conduct their audit and analysis for Information Integrity more frequently than annually (i.e., quarterly), may also conduct the follow-up audit of effectiveness more frequently. The audit must be within the 3–6 month time frame prescribed by NCQA.
Applicable Standards:
HP: CR 8, Element C; CR 8, Element D, factor 2. UM 12, Element D, UM 12, Element E, factor 2; UM 12, Element F, UM 12, Element G, factor 2.
CRPN: CR 2, Element C, CR 2, Element D, factor 2.
MBHO: CR 8, Element C; CR 8, Element D, factor 2. UM 11, Element D, UM 11, Element E, factor 2; UM 11, Element F, UM 11, Element G, factor 2.
HP 2025
In this example, the organization may demonstrate compliance with QI 3, Element A by providing evidence that it reported 50% of required measures it is capable of reporting. The organization would be required to report a valid, numeric rate for at least 50% of the required nonbehavioral health measures (i.e., 2 of the 4).
HP 2025
