FAQ Directory

Yes. Given the audit’s current and future importance, NCQA will use the HEDIS MY 2026 Technical Update to add program information to the Volume 2 publication.

This information resides in HEDIS Volume 5 and the Audit Program Code of Conduct. Adding it to Volume 2 enhances the information’s accessibility for all organizations participating in HEDIS.

Anticipate additional information in the following Volume 2 sections:  

NCQA HEDIS Compliance Audit Program Description

• References to the standardized HEDIS Compliance Audit methodology: All Licensed Organizations and Certified HEDIS Compliance Auditors use this method without deviation. All health plans reporting HEDIS are held to the same standards and requirements in HEDIS Volume 5. 
• References to the strict requirements for audit independence: All Licensed Organizations and auditors must avoid conflicts of interest, including perceived conflicts of interest, and are prohibited from providing technical assistance or advisory services to organizations that they audit. Noncompliance may result in revocation of licensure and certification status.

General Guideline: Preparing for the Audit

• A description of supplemental data validation: Information will summarize requirements and timing for all supplemental data sources undergoing validation. 
• A description of preliminary rate review: Information will summarize requirements for preliminary rate submission through the IDSS, and emphasize expectations for organizations to substantiate changes in performance rates.

This applies to the following Programs and Years:

As long as you submit scorable rates for at least 50% of the HPR measures by weight, per applicable product line and have a numerical rating (1-5) on at least one subcomposite under all three composites, we will calculate and display your measure rates and a numerical overall rating (0-5) on the September 15 release of HPR on the NCQA Health Plan Report Card.

This applies to the following Programs and Years:

Member-reported data are allowed in specific scenarios, and when all requirements are met.

Organizations may not call members to collect HEDIS data. The expectation is that member-reported data are generated during an encounter where the member receives care.   

Some HEDIS data are reported by members; for example, when standardized assessment tools are used (e.g., PHQ-2), or when documenting language preference, race and ethnicity.  

Services and biometric values reported by members are permitted if they adhere to the following guidelines in HEDIS Volume 2:

• Member-Reported Services and Biometric Values general guideline. Member-reported services may be used if collected by a PCP or specialist (if the specialist is providing a primary care service related to the condition being assessed, in the course of taking a member’s history), and if the information is in the member’s health record. 
• Supplemental Data general guideline.
  Information on services reported by members often reside in non-standard supplemental sources. The supplemental data general guideline states that there must be evidence of provider accountability for the information documented. Documentation of member-reported services must be complete (date, place of service, procedure, prescription, test result or finding, practitioner type).

This applies to the following Programs and Years:

Provider attestations or portal data are allowed in specific scenarios and when all requirements are met.

Organizations may obtain information from providers on services that were rendered via attestation forms or provider portal interfaces. These are considered supplemental sources, and must be substantiated with proof-of-service documentation (e.g., original medical record).

In particular, organizations may not use provider attestations or data entered in an electronic platform as evidence that a service was rendered (i.e., as proof of service). This includes attestation forms filed in the member’s record, which are not primary sources for the information.

This applies to the following Programs and Years:

The following data elements must be present for pharmacy data:

• Generic name (or brand name).
• Strength/dose.
• Route.
• Dispensed or shipped date (i.e., the date when the medication was dispensed or shipped).

Medical record documentation that an individual was prescribed a medication, or that lists current/active medications, does not meet criteria. The dispensed date is required. For mailed prescriptions, the shipped date is considered the dispensed date.  

This applies to the following Programs and Years:

Proof of service is the primary source documentation for a service or a result (not a secondary representation of the information), and should originate from the source system where it was first documented.

Acceptable proof of service:

• A copy of the information from the member’s chart from the service provider or PCP.
• A copy of the clinical report or clinical summary from the visit for service, such as lab or radiology reports.
• A screen shot of the EHR records or state- or county-sponsored immunization registry records.

Proof of service is primary source documentation, not a secondary representation of that information. The following provide examples that are not considered proof of service:

• C-CDA or FHIR files are electronically generated, and are not proof of service. 
• Attestation forms are not the original source of documentation for an encounter, and are not proof of a service or result. 

This applies to the following Programs and Years:

No. Effective immediately, NCQA changed its policy regarding Medicaid sanctions and exclusions. The State Medicaid agency is no longer a required source; it is now considered an optional source. 

For Medicaid sanctions, organizations may use any of the following sources: 

• State Medicaid agency. 
• AMA Physician Master File. 
• Federation of State Medical Boards (FSMB). 
• National Practitioner Data Bank (NPDB). 
• SAM.gov. 

For Medicaid exclusions, organizations may use any of the following sources: 

• State Medicaid agency. 
• List of Excluded Individuals and Entities (LEIE) maintained by the Office of Inspector General (OIG). 
• National Practitioner Data Bank (NPDB). 

Note: A related question was posted on July 15, 2025: “Obtaining Sanction and Exclusion information from the State Agency“. This FAQ replaces that post. 

This applies to the following Programs and Years:

The July 1, 2025, date is incorrect. For the 2026 standards and guidelines, factor 7 is scored NA for appeal notifications issued before July 1, 2026.  

This applies to the following Programs and Years:

No. Effective immediately for delegation oversight standards, organizations receive automatic credit for the delegation agreement semiannual reporting requirement in Element A, and for the delegation oversight semiannual report evaluation in Element C, when an NCQA-Accredited/Certified delegate performs an NCQA-required activity.  

For example, in Health Plan Accreditation, NET 6, Element A, factor 3 and NET 6, Element C, factor 3 receive automatic credit for an NCQA-Accredited/Certified delegate. 

This applies to all products. 

Note: This updated FAQ replaces the original version published on September 15, 2025. 

This applies to the following Programs and Years:

No. BPD-E will not be publicly reporting for MY 2026; NCQA will allow voluntary ECDS reporting for BPD-E. The administrative and hybrid version of the BPD measure will continue to be publicly reported for MY 2026.

This applies to the following Programs and Years:

Yes. The LSC-E, SPC-E and SPD-E measures will be publicly reported for MY 2026.

This applies to the following Programs and Years:

Yes. Some appendices were removed from the publication. This approach for HEDIS MY 2026 reduced redundancy, considered the broader product changes and whether users might prefer to engage with information outside the publication.

For example, as an alternative to Appendix 2: Technical Considerations for New Measures, clinical guideline recommendations for each measure are included directly in the measure specifications. NCQA also updated the State of Health Care Quality Report to reflect the latest HEDIS measure set release, including new measures for MY 2026. The State of Health Care Quality Report is publicly available at NCQA.org.

NCQA is committed to supporting stakeholders who use HEDIS, and we welcome feedback as we continue to evolve HEDIS.

This applies to the following Programs and Years: