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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11.22.2023 CM 04 For CM 04, what does it mean that the care plan must show patient involvement in its creation?

The document should not simply be a hardcoded paper that auto-populates structured fields from the EHR into the document. It should contain language showing that the patient provided input and understands the plan. NCQA is not prescriptive on specific verbiage that must be in the care plan. 

The intent of CM 04 is to give the patient ownership and the power to improve their health outcomes. Engaging the patient in the development of their care plan can result in greater success and adherence to treatment goals.  

PCMH 2017

11.22.2023 CM 04 For CM 04, what does “the care plan is written at a health literacy level accessible to the patient” mean?

This means that the information is not all medical jargon. So instead of the care plan stating, “1 PO BID”, the practice may say “take one by mouth two times a day.” Instead of hardcoded complex diagnosis names and codes, write the diagnosis in common language. For example, instead of only providing the diagnosis of “dyspnea,” use “shortness of breath.”  

The intent is to ensure that the patient understands his/her condition(s), goals, and plans to follow to improve their health.  

PCMH 2017

11.16.2023 MY 2023 Race and Ethnicity Stratification (RES) HEDIS Compliance Audit Requirements Are there new audit requirements for race and ethnicity stratification reporting for MY 2023?

No. Volume 5: HEDIS Compliance Audit MY 2023 does not include new requirements for reporting race and ethnicity. Consistent with MY 2022, these data are addressed in the HEDIS Roadmap. Auditors must confirm that organizations provide a complete Roadmap response, and review all attachments describing data flow, layout and transformation. Roadmap Section 6, Question 6.3J requires organizations to describe the sources they use, their processes for disaggregating race and ethnicity fields, their data source reconciliation and prioritization processes and the percentage of members with available data.  

NCQA introduced a direct data threshold of ≥20% for Race/Ethnicity Diversity of Membership (RDM) in the 2024 Health Plan Ratings scoring methodology. Please note that this is independent from the race and ethnicity stratifications, and should not impact audit designations. There are no bias thresholds for the race and ethnicity stratifications in Volume 5.

HEDIS 2023

11.16.2023 Definition of “Unknown” reporting category for race and ethnicity values When can organizations report race and ethnicity as an “Unknown” value?

“Unknown” race and ethnicity values indicate missing data. Two criteria must be met to report “Unknown”: 

1. There is no recorded value, and  

2. The organization did not receive a declined response from the member. 

Starting in MY 2023, all “Unknown” values must be attributed to an unknown data source. This is a change from MY 2022, when “Unknown” values were attributed to an indirect data source.   

HEDIS 2023

11.16.2023 Data source for “Asked But No Answer” reporting category To what data source should organizations attribute the “Asked But No Answer” race and ethnicity reporting category?

The “Asked But No Answer” reporting category reflects members who were asked for race or ethnicity data, but who declined to provide a response. This reporting category must be attributed to a direct data source because the members self-reported by declining to answer.

HEDIS 2023

11.16.2023 Sources with populated race or ethnicity values of “Unknown” or “Two or More Races” How should organizations handle data sources with values of “Unknown” or “Two or More Races”?”

NCQA strongly discourages using “Unknown” and “Two or More Races” response categories when collecting race and ethnicity data. When possible, organizations should instead use and encourage alternatives such as: 

  • “Other” or “None of the above” response options for members who are unsure of their race or ethnicity. 

  • The ability to select multiple race values for members with two or more races. 

If “Unknown” or “Two or More Races” are populated values in sources where health plans cannot improve response terms/options, they can be mapped to the “Some Other Race” reporting category. 

HEDIS 2023

11.15.2023 Codes for Race and Ethnicity Stratification (RES) Are LOINC codes used to identify race and ethnicity?

No. Codes to identify race and ethnicity resemble some LOINC codes (i.e., the same format), but are derived from a code system developed by the U.S. Centers for Disease Control and Prevention (CDC).
The code is the same across terminologies in multiple instances. NCQA recommends that organizations establish data quality controls to avoid inadvertent data reporting errors. For example, “2106-3” could result in errors if used incorrectly:

  • 2106-3 = “White” (CDC Race and Ethnicity).
  • 2106-3 = “Choriogonadotropin (pregnancy test) [Presence] in Urine” (LOINC).

HEDIS 2024

11.15.2023 HEDIS Roadmap Documentation Requirements for Aggregators What HEDIS Compliance Audit Roadmap documentation is required by health plans for data sources provided from an aggregator (e.g., health information exchange)?

It depends:

  • For data streams provided by aggregators with a current approved validation status in the NCQA Data Aggregator Validation program, only Roadmap Section 5 from the plan is required. 
  • For all other data streams provided by aggregators that are not validated in the DAV program, a Roadmap Section 5 from the plan and Section 5a from the aggregator are required.

NCQA maintains an online directory of entities with validated data streams.

HEDIS 2024

11.15.2023 Cervical Cancer Screening (CCS, CCS-E) & Adults’ Access to Preventive/Ambulatory Health Services How should allowable gaps be evaluated when there is a leap year? For example, if the year prior or 2 years prior to the measurement year is a leap year, should the allowable gap calculation include all the days in the calendar year that is 2 years prior to measurement year, but falls outside of the 730 days prior to the measurement year?

No, if there are days in the calendar year that fall outside of the 730 days prior to the measurement they should not be included in the continuous enrollment criteria or counted towards the allowable gap days. Only the period covered by continuous enrollment (e.g., January 2–December 31, 2025 for HEDIS MY 2025 reporting) should be used when assessing the allowable gap. The years of enrollment for allowable gap evaluation should consist of 365 periods.
For example, not having coverage on January 1, 2023, does not count as a gap in enrollment for calendar year 2023 for HEDIS MY 2025 reporting. The following periods should be used for allowable gap evaluation:

  • Year 1: January 2, 2023–January 1, 2024
  • Year 2: January 2, 2024–December 31, 2024
  • Measurement year: January 1–December 31, 2025

HEDIS 2024

11.15.2023 Notice of Medicare Non-Coverage (NOMNC) Denials For the UM file review universe, should plans include concurrent denials for Medicare members that involve issuance of a Notice of Medicare Non-Coverage (NOMNC) document?

No. Notice of Medicare Non-Coverage (NOMNC) denial files are out of NCQA’s scope of review and should be excluded from the UM file universe.

HP 2024

11.15.2023 Using SAM.gov for Medicare/Medicaid Sanctions Is SAM.gov an acceptable source for verifying Medicare and Medicaid sanctions?

Yes. Organizations may use SAM.gov to verify Medicare and Medicaid sanctions for CR 3, Element B, factor 2 and CR 5, Element A, factor 1.

HP 2024

11.15.2023 CVO: Using SAM.gov for Medicare/Medicaid Sanctions Is SAM.gov an acceptable source for verifying Medicare and Medicaid sanctions?

Yes. Organizations may use SAM.gov to verify Medicare and Medicaid sanctions for CVO 11, Element A and CVO 14, Element C.

CVO 2022