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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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
TopicUpdate Highlights
Standards and Guidelines / Appendix 7The 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 GuidelinesAdded the ‘Site-Specific’ and ‘Cross-Program Shared Credit Option’ symbols to all relevant criteria.
Standards and Guidelines/ Appendix 6The new appendix outlines the updated Merger, Acquisition and Consolidation Policy for Recognition Programs policy.
TC 03Updated language describing an appropriate external PCMH collaborative and clarified than participation in an HIE will not meet the requirement.
TC 08Highlighted the behavioral healthcare manager may conduct their duties through telehealth.
TC 09Specified that if appointments are conducted using telehealth, the practice should have a process for informing patients about the availability.
KM 04Clarified that the practice must use a standardized screening tool and have a process for following up on results.
KM 05Clarified 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 09Specified that age and gender are not acceptable as a third aspect of diversity.
KM 11ASpecified 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 13Specified that excellence in a performance-based recognition programs must be at the site level.
AC 01Specified 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 03Highlighted that same-day appointments and after-hours appointments may be conducted through telehealth.
AC 03Clarified that an ED cannot be used to provide appointments outside business hours.
AC 04 and AC 08Clarified that the report includes calls or messages received both during and after office hours.
AC 05Specified that clinical advice documentation is inclusive of telehealth appointments.
AC 06Clarified that disease specific appointments, home visits and group visits do not meet the intent of the criterion.
AC 12Stated that continuity of the medical record is inclusive of telehealth appointments.
CM 02Specified that small sites and satellite sites may share a care management population with NCQA approval.
CM 03Specified that comprehensive risk stratification must include at least 3 of the categories outlined in CM 01.
CM 04 – CM 08Specified that care plans must be established for at least 75% of patients identified for care management.
CC 09Clarified that the agreement may be with a contracted behavioral telehealth provider.
CC 10Clarified 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 16Highlighted that follow-up visits may be conducted through telehealth.
CC 21Clarified that electronically exchanging information should include data both sent and received.
QI 04BClarified that the report provided should summarize collected feedback.
QI 05Updated the vulnerable patient population definition.
QI 01 and QI 02Clarified that measures include activities conducted during telehealth visits.
QI 03Specified that major appointments may be conducted in person or via telehealth.
QI 04Clarified that the access category may include questions regarding telehealth.
Policies and ProceduresAdded a description of telehealth in NCQA recognition programs.
Policies and ProceduresUpdated the reconsideration process.
Policies and ProceduresThe “Discretionary Audit” is now called the “Discretionary Review”.
 

PCMH 2017

4.07.2020 CM 01 Could a chronic condition be considered under the high cost/high utilization category if it is expensive to treat?

The intent behind the high cost/high utilization category is that the practice is actively measuring the total cost of services or how much utilization occurs. A diagnosis of a condition may not be used as a proxy for high cost/high utilization. For instance, measuring the number of patients with uncontrolled asthma would not count under high cost/high utilization, but if those patients have multiple ER visits per year, this would be considered high utilization.

PCMH

4.07.2020 QI 11 May a practice use qualitative feedback to meet QI 11?

To meet criterion QI 11 a practice must first establish a baseline for a patient experience measure and then set goals and take actions to improve upon this measure. Qualitative measures can be used if the qualitative feedback can be measured and the baseline can be compared to any improvement. An example of this may be the practice trying to reduce the total number of negative feedback responses they receive through a suggestion box pertaining to wait times by 50%.

PCMH 2017

4.07.2020 TC 04 & QI 17 Can a large organization meet TC 04 and QI 17 through a shared Patient and Family Advisory Council (PFAC)?

Organizations may share a Patient and Family Advisory Council (PFAC) among sites as long as every site has representation on the council. Large organizations with many sites may consider creating multiple PFACs based on region or clinic type.

PCMH 2017

4.07.2020 TC 03 Would being connected to an HIE or RHIO meet the intent of TC 03?

No, connection to an HIE or RHIO alone would not meet the intent of TC 03. A PCMH collaborative activity must be external to practice, involve multiple practices, be ongoing (not a short-term activity), cover multiple aspects of patient-centered care, and involve some level of collaboration between practices to learn and share best practices with their peers. Connection to an HIE or RHIO may help the practice meet elective criterion CC21A.

PCMH 2017

4.07.2020 KM 13 Do benchmarked/ performance-based recognition programs at the organization or health system level meet KM 13?

No, organization or health system involvement in a benchmarked/ performance-based recognition program will not meet. For KM 13, the practice must participate in an external recognition program that assesses the practice or clinician-level performance, using a common set of specifications to benchmark results. The external recognition program should also publicly report results and have a process to validate measure integrity.

PCMH 2017

4.07.2020 AC 04 For AC 04, must a practice report on calls during and after business hours?

Yes, to meet AC 04 a practice’s report must include calls received both during and after business hours. If the practice has different standard response time expectations during and after business hours, they may format this as two separate reports.

PCMH 2017

4.06.2020 AC 10 & 11 If there is one MD practicing at a site with mid level providers (PA, APRN) would this be considered a solo site for AC 10 and AC 11?

If a PA or an APRN shares a panel of patients with a physician then that team would be considered a solo site since all patients are assigned to the primary provider with a single panel.
If the PA or APRNs that have their own panel of patients and can be selected as a patient’s primary care clinician, the site would not be considered a solo site.

PCMH 2017

12.03.2019 AC 03 How does NCQA define “regular business hours”? Our practice is open from 8 am–5 pm. Would opening from 7 am–4 pm meet the requirements of this criterion?

By “regular business hours,” NCQA means 8 am-5 pm, Monday-Friday. The practice determines its hours of operation. Offering appointments between 7am and 4pm meets the criterion. The intent is that practices provide appointments outside typical business hours, to accommodate patients’ access needs. A practice could also shift staff hours—some staff work from 7 am-4 pm weekdays; some staff work from 8 am-5 pm weekdays—to enhance access.

PCMH 2017

10.11.2019 QI 08 - QI 14 Why are the QI Worksheet and the reports for QI 08 – QI 14 not eligible for virtual review?

Reports submitted for QI often outline a lot of information (baseline performance, goals, actions, and remeasurements) that must be carefully reviewed. By uploading the documents ahead of the virtual review, it gives the Evaluator time to review the data and note areas for clarification.
 

PCMH

7.15.2019 QI 04B Would a Patient Family Advisory Council (PFAC) be acceptable as qualitative feedback for QI 04B?

The evidence must specifically reflect the practice’s patient population. Standalone practices whose PFAC only includes patients and family members from the practice may use it to meet QI 04B. For practices that are a part of an organization with other primary care practices under the same umbrella, a shared PFAC would not meet QI 04B. While an organization with a shared PFAC in most cases cannot use it as evidence for QI 04B, it may be used it to demonstrate shared evidence to meet elective criteria TC 04 (2 credits) and QI 17 (2 credits).

PCMH 2017

5.07.2019 QI 08 & AR QI 03 Would increasing survey response rate qualify as a measure for improving patient experience ( QI 11, AR QI 03)?

No, increasing survey response rate is important in obtaining more representative patient feedback, but would not meet the intent of QI 08 or AR QI 03. The response rate is part of the platform for obtaining the feedback, while the measure for these criteria should be improving the feedback itself.
 

PCMH 2017