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.

Filter Results
  • Save

    Save your favorite pages and receive notifications whenever they’re updated.

    You will be prompted to log in to your NCQA account.

  • Email

    Share this page with a friend or colleague by Email.

    We do not share your information with third parties.

  • Print

    Print this page.

expand all

6.25.2020 July 2020 PCMH Summary of Changes What changes were made to the PCMH Standards and Guidelines?

PCMH (Version 6) Summary of Changes
Topic Update Highlights
Standards and Guidelines / Appendix 7 The New York State PCMH program was integrated into the PCMH Standards and Guidelines and is no longer a separate publication. The ‘NYS’ icon was added to all 12 required criteria for NYS PCMH. The new Appendix 7,  NYS PCMH Recognition Program, outlines the specifics of the NYS program.
Standards and Guidelines Added the ‘Site-Specific’ and ‘Cross-Program Shared Credit Option’ symbols to all relevant criteria.
Standards and Guidelines/ Appendix 6 The new appendix outlines the updated Merger, Acquisition and Consolidation Policy for Recognition Programs policy.
TC 03 Updated language describing an appropriate external PCMH collaborative and clarified than participation in an HIE will not meet the requirement.
TC 08 Highlighted the behavioral healthcare manager may conduct their duties through telehealth.
TC 09 Specified that if appointments are conducted using telehealth, the practice should have a process for informing patients about the availability.
KM 04 Clarified that the practice must use a standardized screening tool and have a process for following up on results.
KM 05 Clarified that asking patients for the date of their last dental exam or providing a list of local dentists does not meet the intent of the criterion.
KM 09 Specified that age and gender are not acceptable as a third aspect of diversity.
KM 11A Specified that the identification of a disparity in care/service for a vulnerable group should be driven by the practice’s data and compared to the general practice population. Actions taken to reduce the disparity should be specific to that vulnerable group.
KM 13 Specified that excellence in a performance-based recognition programs must be at the site level.
AC 01 Specified that AC 01 focuses on assessing patient access needs and preferences specific to appointments. Also clarified that this differs from more general patient experience assessment of access in QI 04.
AC 02-AC 03 Highlighted that same-day appointments and after-hours appointments may be conducted through telehealth.
AC 03 Clarified that an ED cannot be used to provide appointments outside business hours.
AC 04 and AC 08 Clarified that the report includes calls or messages received both during and after office hours.
AC 05 Specified that clinical advice documentation is inclusive of telehealth appointments.
AC 06 Clarified that disease specific appointments, home visits and group visits do not meet the intent of the criterion.
AC 12 Stated that continuity of the medical record is inclusive of telehealth appointments.
CM 02 Specified that small sites and satellite sites may share a care management population with NCQA approval.
CM 03 Specified that comprehensive risk stratification must include at least 3 of the categories outlined in CM 01.
CM 04 – CM 08 Specified that care plans must be established for at least 75% of patients identified for care management.
CC 09 Clarified that the agreement may be with a contracted behavioral telehealth provider.
CC 10 Clarified that behavioral health integration may be done through behavioral telehealth.
CC 13

Clarified and updated the expectations for engagement regarding cost implications of treatments options. Practices should not only engage with patients regarding cost implications of treatment options, but also provide information about current coverage and make connections to financial resources as needed.
CC 16 Highlighted that follow-up visits may be conducted through telehealth.
CC 21 Clarified that electronically exchanging information should include data both sent and received.
QI 04B Clarified that the report provided should summarize collected feedback.
QI 05 Updated the vulnerable patient population definition.
QI 01 and QI 02 Clarified that measures include activities conducted during telehealth visits.
QI 03 Specified that major appointments may be conducted in person or via telehealth.
QI 04 Clarified that the access category may include questions regarding telehealth.
Policies and Procedures Added a description of telehealth in NCQA recognition programs.
Policies and Procedures Updated the reconsideration process.
Policies and Procedures The “Discretionary Audit” is now called the “Discretionary Review”.
 

PCMH 2017

6.25.2020 July 2020 PCSP Summary of Changes What changes were made to the PCSP Standards and Guidelines?

PCSP (Version 3) Summary of Changes
Topic Update Highlights
Standards and Guidelines Added the ‘Shared Credit’ symbol to all relevant criteria.
Standards and Guidelines/ Appendix 4 The new appendix outlines the updated Merger, Acquisition and Consolidation Policy for Recognition Programs policy.
TC 03 Updated language describing an appropriate external patient-centered collaborative activities and clarified than participation in an HIE will not meet the requirement.
TC 08 Specified that if appointments are conducted using telehealth, the practice should have a process for informing patients about the availability.
RM 11 Highlighted that this criterion is particularly relevant to self-referred patients.
KM 04 Specified that monitoring pain or functional health status may not be appropriate for all specialties, so if the category is not relevant or appropriate, a practice should make a different selection.
KM 05 Clarified that the practice must use a standardized screening tool and have a process for following up on results.
KM 06 Specified that age and gender are not acceptable as a third aspect of diversity.
KM 15 Clarified that patients should be proactively reminded of needed services related to the specialty.
KM 20 Specified that excellence in a performance-based recognition programs must be at the site level.
AC 01 Clarified that the focus of the criterion is to ensure that patients have access to the practice for urgent needs.
AC 02 and AC 03 Stated that the reports include calls or messages received both during and after office hours.
AC 04 Specified that clinical advice documentation is inclusive of telehealth appointments.
AC 05 Stated that continuity of the medical record is inclusive of telehealth appointments.
PM 01 and PM 11 Clarified the guidance in PM 01 by moving the reference to motivational interviewing and treatment goals to PM 11.
CC 09 Highlighted that follow-up visits may be conducted through telehealth and that follow-up should be consistently documented.
CC 13 Clarified that electronically exchanging information should include data both sent and received.
QI 01F Clarified that the report provided should summarize collected feedback.
QI 01 Clarified that measures include activities conducted during telehealth visits.
QI 01D. Specified that major appointments may be conducted in person or via telehealth.
QI 01E. Clarified that the access category may include questions regarding telehealth.
QI 05 Updated the vulnerable patient population definition.
Policies and Procedures Added a description of telehealth in NCQA recognition programs.
Policies and Procedures Updated the reconsideration process.
Policies and Procedures Doctoral or master's level certified or licensed chemical dependency counselors have been added as eligible clinicians to the program.
Policies and Procedures The “Discretionary Audit” is now called the “Discretionary Review”.

PCSP 2019

6.15.2020 Updated: UM 11- Outsourcing Storage of Utilization Management Data To External Entities How many contracts does NCQA review for Elements A and B, factor 6 if an organization outsources UM data to external entities?

If an organization contracts with external entities to store its own UM data or contracts with UM delegates that store data, NCQA reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four.

MBHO 2020

6.15.2020 Updated: CR 1, Element C- Outsourcing Storage of Credentialing Data To External Entities How many contracts does NCQA review for Element C, factor 4 if an organization outsources credentialing data to external entities?

If an organization contracts with external entities to store its own credentialing data or contracts with CR delegates that store data, NCQA reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four

MBHO 2020

6.15.2020 UM 12: Outsourcing Storage of Utilization Management Data To External Entities Are cloud-services data storage providers included among the external entities for which NCQA reviews contracts for Elements A and B, factor 6?

NCQA includes external entities that store, create, modify or use UM data for any function covered by the UM standards on behalf of the organization in the scope of Elements A and B, factor 6, with the exception of organizations whose only UM service provided for  the organization is to provide cloud-based data storage functions and not services that create, modify or use UM data.

UM-CR-PN 2020

6.15.2020 MBHO UM 11 : Outsourcing Storage of Utilization Management Data To External Entities Are cloud-services data storage providers included among the external entities for which NCQA reviews contracts for Elements A and B, factor 6?

NCQA includes external entities that store, create, modify or use UM data for any function covered by the UM standards on behalf of the organization in the scope of Elements A and B, factor 6, with the exception of organizations whose only UM service provided for  the organization is to provide cloud-based data storage functions and not services that create, modify or use UM data.
 

MBHO 2020

6.15.2020 CR 1C: Outsourcing Storage of Credentialing Data To External Entities Are cloud-services data storage providers included among the external entities for which NCQA reviews contracts for Element C, factor 4?

NCQA includes external entities that store, create, modify or use CR data for any function covered by the CR standards on behalf of the organization in the scope of Element C, factor 4, with the exception of organizations whose only CR service provided for  the organization is to provide cloud-based data storage functions and not services that create, modify or use CR data.
 

MBHO 2020

6.15.2020 Product Line Scoring What is the expectation for HPA 2020 product line scoring?

For elements that are reviewed and scored by product line, NCQA expects to see evidence or documentation for each product line. Each product line is scored separately.

For reports, it is acceptable to have one document if the data or analysis for each product line is clearly separated within the document. If a single documented process or policy and procedure applies to multiple product lines, the documented process must state the product lines to which it applies. For materials, if a single document applies to more than one product line, the organization must demonstrate this.
For elements that are not designated to be reviewed and scored by product line, NCQA reviews one document for the element if the product lines are managed the same. Documentation must demonstrate that it applies to all product lines included in the survey (e.g., data and analysis may be combined for a report, but it must be clear that they represent all included product lines).

Evidence in documentation does not need to be separated by product lines; all product lines receive the same score. However, if product lines are managed differently, the element is treated as if it was designated to be reviewed and scored by product line, as described above.

HP 2020

6.15.2020 Updated: Distribution of Rights and Responsibility to Existing Members and Practitioners Does distributing the members rights and responsibilities statement to all members and practitioners annually, whether requested or not, meet the intent of ME 1, Element B, factors 2 and 4 (RR 1, Element B, factors 2 and 4 in MBHO)?

Yes. Distributing the rights and responsibilities statement to all members and practitioners (new upon enrollment and annually to existing) is acceptable, because it is consistent with prior years' and exceeds the standards effective July 1, 2020. Factors 2 and 4 will be scored yes; organizations are not required to track requests for existing members and practitioners during the look-back period.

MBHO 2020

6.15.2020 Updated: UM 12- Outsourcing Storage of Utilization Management Data To External Entities How many contracts does NCQA review for Elements A and B, factor 6 if an organization outsources UM data to external entities?

If an organization contracts with external entities to store its own UM data or contracts with UM delegates that store data, NCQA reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four.

UM-CR-PN 2020

5.15.2020 UM 5: Medicaid lookback period For Renewal Surveys, the look-back period is specified as 6 months for the Medicaid product line in UM 5, Elements A-C. Is this correct?

No. The look-back period should be specified as 12 months for all product lines, for Renewal Surveys, which is consistent with the other file review standards and elements. NCQA initially changed the scope of review to account for a change made to verbal notification and how it no longer affords organizations an extension.

However, because of this error, if an organization does not meet a factor in UM 5, Elements A-C within the first 6 months of the look-back period, NCQA does not penalize the organization and scores the file “NA” instead of “Not Met” for Medicaid surveys.

MBHO 2020

4.28.2020 COVID-19 If an organization opts not to report for HEDIS 2020, may it use its HEDIS 2019 (MY 2018) audited reportable hybrid rates when considering sample size reduction for HEDIS MY 2020 reporting?

Yes. Due to changes in reporting requirements because of COVID-19, organizations that do not report HEDIS 2020 results this year may use their audited HEDIS 2019 (MY 2018) reportable hybrid rates when considering sample size reduction rules for HEDIS MY 2020 reporting. In addition, if an organization is required to report their MY2019 administrative rate for HEDIS 2020, they will still be able to use their audited HEDIS 2019 (MY 2018) reportable hybrid rates when considering sample size reduction.

 

HEDIS 2020