FAQ Directory

Yes. The "Handling Missing Values" table in the Related Information section is incorrect for the BR, NR and NQ audit designations. If any measure has a BR (Biased Rate), NR (Not Reported) or NQ* (Not Required) audit designation, it is assigned a rating of 0 and included in the calculation of the 3.0 average.

The information above is a correction to the Policy Update issued in March 2026 for QI 3, Element B.

*Accredited health plans may not use the NQ audit designation for measures included in the Health Plan Ratings measure list.

Applicable standards: 
•    Health Plan Accreditation: QI 3, Element B

This applies to the following Programs and Years:

The stem for HO 2, Element D should read as follows: "The organization's methods for evaluating member or patient disability status include:" 
Note: Although the stem appears in the e-publication version of the standards, it is not visible in the IRT version of the standards. This will be updated in the IRT version in August 2026.

Applicable standards:

• Health Outcomes and Community-Focused Care Accreditation – HO 2, Element D

This applies to the following Programs and Years:

For the 2026 standards year only, NCQA is limiting the expanded monitoring requirement under CR 5, Element A, factor 3 to practitioners initially credentialed on or after July 1, 2026. Organizations are not required to apply this expanded monitoring requirement to practitioners credentialed before this date. 

For the 2027 standards year and beyond, the expanded requirement applies to all practitioners for surveys on or after July 1, 2027.

Applicable Standards:

• HPA: CR 5, Element A, factor 3
• BHA: CR 5, Element A, factor 3
• CRPN: CRA 5, Element A, factor 3 and CRC 12, Element B, factor 3

This applies to the following Programs and Years:

For PHM 2, Element B, factor 4 the organization must assess the needs of members with serious mental illness (SMI) and assess the needs of members with serious emotional disturbance (SED). If a member has both conditions, separate assessments are not required under factor 4. The organization determines if the member is assessed as a member with SMI or SED.

Applicable standards: 
•    Health Plan Accreditation – PHM 2, Element B
•    Behavioral Health Accreditation – PHM 2, Element B

This applies to the following Programs and Years:

UM approval and denial rates are calculated at the request level, not at the service or code level. A request is counted once in the denominator, regardless of how many services it includes. If any part of the request is approved, it counts as 1 approval. If any part is denied, it counts as 1 denial. Therefore, a partially approved and partially denied request is included in both the approval and denial rates.

For example, if one authorization request includes three CPT codes and one is approved while two are denied, the organization counts:

• 1 approval decision (count in the approval rate numerator),
• 1 denial decision (count in the denial rate numerator),
• 1 authorization request (count once in the approval and denial denominator).

As another example, if an organization made decisions on 300,000 total authorization requests, and:

• 200,000 were completely approved,
• 50,000 were partially approved/denied, and
• 50,000 were completely denied,

the rates would be calculated as follows:

• Overall approval rate: ((200,000 + 50,000) / 300,000) x 100 = 83%.
• Overall denial rate: ((50,000 + 50,000) / 300,000) x 100 = 33%.

The overall approval rate cannot exceed 100%, and the overall denial rate cannot exceed 100%. However, if an organization sums these two rates, the combined total may exceed 100%.

Applicable standards:

• Health Plan Accreditation – UM 1, Elements B-E
• Behavioral Health Accreditation – UM 1, Elements B-D
• Utilization Management Accreditation – UM 3, Elements B-E

This applies to the following Programs and Years:

No. To align with HPA, NCQA does not review communication to practitioners about the availability of UM criteria in UM 4, Element B in UM Accreditation or BHA. Instead, NCQA evaluates whether the organization makes the criteria available electronically (e.g., through an EHR, portal, or website). Acceptable evidence includes system reports or screenshots demonstrating how practitioners access the criteria at the point of care.

Applicable standards:

• Utilization Management Accreditation – UM 4, Element B
• Behavioral Health Accreditation – UM 2, Element B

This applies to the following Programs and Years:

• 20 are fully overturned, and
• 10 are partially overturned.

• Health Plan Accreditation – UM 1, Element E
• Behavioral Health Accreditation – UM 1, Element C
• Utilization Management Accreditation – UM 3, Element E
  

This applies to the following Programs and Years:

No. For the Exchange product line, COVID-19 is not included in the Plan All-Cause Readmissions (PCR) risk adjustment calculations.

References of COVID-19 in the “Risk Adjustment Determination” narrative and introductory text of the Risk Adjustment Calculation section is an error. The PCR COVID-19 related discharge adjustments only apply to the Medicare product line for MY 2026.

This applies to the following Programs and Years:

Exchange MY 2026

This applies to the following Programs and Years:

If delegates that render medical necessity determinations do not have access to, manage, or handle UM request receipt dates or UM decision notification dates for any client—and no receipt or notification dates are stored in the delegates’ systems—then UM 12, Element C, factors 5–7 may be scored Not Applicable (NA), because the intent of these factors is to evaluate the integrity of receipt and notification dates.

If an organization retains sole responsibility for receiving UM requests, documenting receipt dates, and issuing UM decision notifications—and its delegates render medical necessity determinations only—then UM 12, Element C, factors 5–7 do not apply to those delegates.

Applicable standards:

• Health Plan Accreditation: UM 12, Element C
• Behavioral Health Accreditation: UM 11, Element C
• Utilization Management Accreditation: UM 8, Element C

This applies to the following Programs and Years:

For the purposes of Accreditations in Health Outcomes and Community-Focused Care, a health plan that is seeking accreditation that provides both payor and provider functions (i.e., direct medical or behavioral patient care) is considered both a payer and a care delivery organization. “Direct medical or behavioral patient care” is not intended to include case management for the purposes of Accreditations in Health Outcomes and Community-Focused Care.

A health plan that provides direct medical or behavioral patient care must also meet the following requirements that apply only to care delivery organizations:

• HO 2, Element E.
• HO 2, Element H, factor 5. 
• HO 2, Element I, factor 5.
• HO 2, Element J, factor 5. 
• HO 4, Element A. 
• HO 4, Element B. 
• HO 5, Elements D and E. 

A health plan that does not provide direct patient care is not considered a care delivery organization. It is considered a payer only. The requirements listed above that apply only to care delivery organizations would not apply to a health plan that is a payer only.

This applies to the following Programs and Years:

No. Organizations must use 12 months of continuous data and may use data from the most recent calendar year (e.g., January 1–December 31). The workbook must be completed at least once during the look-back period. 

Applicable standards: 

• Health Plan Accreditation: UM 1, Elements B-H.  
• Behavioral Health Accreditation: UM 1, Elements B-F. 
• Utilization Management Accreditation: UM 3, Elements B-H.

This applies to the following Programs and Years:

For buprenorphine injection dispensing events identified using a medication list, if the days supply is not available in the pharmacy data, count as a 31 days supply.

This applies to the following Programs and Years: