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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11.15.2012 Eligibility for Case Management (CM) What organizations are eligible to pursue Case Management Accreditation?

NCQA considers entities that perform relevant functions to be eligible for NCQA CM Accreditation, including, but not limited to: CM organizations, population health management organizations, health plans (HP), managed behavioral healthcare organizations (MBHO), provider-based organizations– including medical groups, hospitals, integrated delivery systems, patient-centered medical homes (PCMH) and accountable care organizations (ACO), community care teams.

This applies to the following Programs and Years:
CM 2014

11.15.2012 Automatic credit for Case Management (CM) If an organization is NCQA DM Accredited, what documentation does it need submit to receive automatic credit for CM 8: Rights and Responsibilities and CM 9: Privacy, Security and Confidentiality Procedures?

To receive automatic credit for CM 8: Rights and Responsibilities and CM 9: Privacy, Security and Confidentiality Procedures, NCQA DM Accredited organizations should attach a copy of your accreditation certificate in the Interactive Survey System (ISS) to the relevant standards and elements.

This applies to the following Programs and Years:

11.15.2012 Differentiating Between Programs If an organization measures and takes action on both primary care and for specialty care practitioners where the methodology and actions are the same but the measures vary by specialty, is this one or more program?

In general, if an organization has a measure set in which a subset of the measures apply only to some specialties (broadly including primary care as a specialty), where the methodology and actions are the same (e.g. public reporting in the same manner regardless of specialty), NCQA treats that as one program. However, if there is more than one action (e.g. public reporting, P4P), we may count them as two programs (a public reporting program and P4P program).

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Certification for information providers May an information provider earn certification for the pieces it provides (e.g., standards, methodology, underlying data), while its customer (i.e., health plan that publishes the information) pursues other pieces (e.g., member communication and complaints, physician communication)?

No. PHQ consists of the specified certification options: Physician Quality (PQ), Hospital Quality (HQ), or both. Contact phq@ncqa.org to discuss your situation so we can consider additional survey options to meet market needs.

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Following Standardized Measure Specifications Does a program have to use the most recent version of a measure to count it as a standardized measure in Element A?

Yes. The organization must follow the most current measure specifications from the measure steward, even if the NQF endorsement has not been updated.

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Use of patient experience data collected from external organizations Is the use of patient experience data considered part of the program in the following circumstances: 1. The organization incorporates third-party performance information data with its own and then takes action on it (i.e., integrates the third-party data with its own to develop a composite that it reports or uses as the basis of action, such as payment or network or benefit design) 2. The organization provides a link for members on a third-party site so the member can review that information?

For scenario 1, the data must be considered as part of the program being reviewed for PHQ because the organization has incorporated the data with its own or tailored the data and then used the data as a basis for its own action (e.g., reporting, payment or network or benefit design). For scenario 2, if _ as part of its program _ the organization simply provides a link to an external source of performance information on physicians without altering that data and represents it as such, and the organization does not take any action based on the data (e.g., pay any incentive or use data for network or benefit design) then it is not considered part of the program.

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Applicable factors for CM program If some factors are not applicable for our case management program, how would we address it to meet the requirements in CM 2, Element E: Initial Assessment?

For CM 2, Element E, which is a file review element, NCQA is looking for documentation of whether or not you completed the applicable activities listed in CM 2, Element D: Initial Assessment Process. For your program, you would note in your documentation that certain factors are not applicable for that particular patient population.

This applies to the following Programs and Years:
CM 2014

11.15.2012 NA scoring for Renewal Surveys in QI 9 The 2013 edition of HP states that for QI 9, Element D, Performance Measurement, the look-back period for Renewal Surveys is NA. Is this correct?

Yes. QI 9, Element D is NA for Renewal Surveys for all factors. This is because organizations that undergo Renewal Surveys are already required to submit and are scored on preventive health HEDIS measures. Organizations undergoing Interim and First Survey options are not required to submit HEDIS measures.

This applies to the following Programs and Years:

11.15.2012 Physician requests For PQ 2 Element C, could a collaborative manage the process?

Yes. PHQ requirements do not prohibit a collaborative from managing a request for corrections or changes made by physicians, but the organization remains accountable and responsible for responding to complaints from consumers and to requests for changes from physicians or hospitals based on actions taken by the organization.

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Organizational accountability Are organizations responsible for confirming the factors in Element F, or is this the responsibility of an external vendor?

For Element F, the organization must demonstrate that it has a process to verify that it has followed the specifications outlined in Element C (e.g., sample sizes, attribution,statistical validity). If the organization uses a vendor to administer the survey, this process may be performed by the vendor, but documentation demonstrating how the element is met must be included for the PHQ Survey.

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Cost, resource use or utilization measures Are there standardized measures for cost, resource use or utilization? If there are none, what measures are plans using?

At this time, there are no standardized (i.e., endorsed) measures of cost, resource use or utilization at the physician level.

This applies to the following Programs and Years:
PHQ 2013

11.15.2012 Pricing for Derivative Programs How does NCQA determine which pricing tier it places a derivative product in?

NCQA prices a program and any programs it qualifies as derivative programs using the pricing tier that includes the total number of physicians measured in all the programs an organization brings forward. No individual physician is counted more than once for the purposes of determining which pricing tier is used, but the total of all physicians in all programs determines the tier used for every program.

This applies to the following Programs and Years:
PHQ 2013