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.

2.01.2024 Health Plan Ratings State Coverage How does NCQA define “state coverage”?

NCQA defines “state coverage” as the states where a plan is licensed to operate. Plans that submit HEDIS/CAHPS data provide this information each year during the HOQ process. If plans do not submit these data, NCQA uses state licensing and membership data provided for Accreditation or gathered from external sources.


2.01.2024 Health Plan Ratings Impact of Not Reporting a Measure Not on CMS' Required Measure List What happens if a Medicare plan fails to report a HPR-required measure that is not on CMS’-required measure list?

The plan will receive a “0” on the measure and the measure weight is included in the Ratings calculation.


2.01.2024 Health Plan Ratings Projected Ratings Sign-Off Requirement Why are plans required to affirm their projected rating?

NCQA requires plans to review their projected rating as a final quality assurance step in the ratings process. Although the projected information is subject to change (from continued quality checks), plans must affirm that they reviewed their information and have no questions regarding their Accreditation status or projected rating.


1.29.2024 Health Plan Ratings 2024 Measure Weights How does NCQA weigh measures used in HPR 2024?

"1" = Race/Ethnicity Diversity of Membership
"1” = Process measures (e.g., screenings, visits)
“1.5” = Patient experience measures (CAHPS)
“3” = Outcome and intermediate outcome measures (e.g., HbA1c Control, Blood pressure control)

HPR 2024

1.29.2024 Health Plan Ratings Data for Scoring What data is HPR using to score plans?

HPR utilizes HEDIS, CAHPS, and HOS data sets and Measurement Years are dependent on HPR year as well as product lines. To find specific data information on each HPR year, please access that year's Measure List by navigating to this page https://www.ncqa.org/hedis/health-plan-ratings/


1.16.2024 3-Dose-Series Prevnar 20 Pneumococcal Vaccine for Childhood Immunization Status (CIS) When will PCV20 pneumococcal vaccine be added to the pneumococcal conjugate value sets?

We anticipate that PCV20 will be added to the CIS value sets in the HEDIS MY 2024 Technical Update, scheduled for release on April 1, 2024.
Although the PCV20 vaccine is not included in the measure for MY 2023, NCQA does not anticipate this will impact performance. The measure denominator only includes children who were at least 18 months old and expected to have already completed the pneumococcal series by June 2023 (the month when ACIP recommended PCV20).

HEDIS 2024

12.15.2023 Collaboration Between Medical Care and Behavioral Health Care Does collaboration between health plan staff clinicians meet the intent of the collaboration requirement in QI 4, Elements A and B?

Typically, no as health plan staff are not practicing practitioners within the health plan's network. The intent of collaboration requirements are for organizations to demonstrate collaboration between their behavioral healthcare delivery system (network practitioners) and medical care delivery system (network practitioners). 

Note: Demonstrating collaboration with an MBHO is acceptable for the collaboration with “behavioral healthcare practitioners” component of the requirement.

HP 2023

12.15.2023 Updated CR Accreditation Eligibility and Reportable Events The 2024 CR Accreditation standards allow organizations that delegate more than 50% of primary source verifications to be eligible for Credentialing Accreditation, as long as all delegates have NCQA Credentialing Accreditation or NCQA Credentialing/CVO Certification. What happens if a delegate loses Accreditation/Certification status after the organization’s survey?

If an organization delegates more than 50% of primary source verifications and one or more of its delegates loses Accreditation/Certification status, NCQA considers this a Reportable Event. The organization must notify NCQA (through My.NCQA.org) within 30 calendar days.

UM-CR-PN 2024

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

11.22.2023 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

11.16.2023 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

11.16.2023 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