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
  • Email
  • Print
expand all

8.15.2012 Evaluation Options: Standards and Guidelines Where can plans get information about standards points, HEDIS/CAHPS points for accreditation and reporting categories points?

Plans can look in Appendix 1: Standards Points for 2013, in the 2013 Standards and Guidelines, for a summary table of approximate points for each Evaluation Option. Appendix 2: HEDIS and CAHPS Points contains a summary table for approximate points for HEDIS/CAHPS measures. Appendix 3: Points by Reporting Category contains a summary table of points by reporting category.

8.15.2012 Completely overturned denials excluded from file review Are overturned denials excluded from file review for only UM 9, Elements C and D, or from all elements in UM 9?

Files processed on or after November 1, 2012, are not included in file review for any element in UM 9.

8.15.2012 Evaluation Options: Status and Scoring Is it possible for plans to score higher than Accredited status during any First Evaluation Option years?

Yes. Plans that notify NCQA that they want to be scored on HEDIS/CAHPS measures by December 31 (before the June HEDIS reporting date) may score higher than Accredited status.

8.15.2012 Evaluation Options: Status and Scoring Does NCQA publish denials for plans undergoing the Interim Evaluation Option or the First Evaluation Option?

No. NCQA does not publish denials for plans undergoing the Interim Evaluation Option or the First Evaluation Option.

8.15.2012 Evaluation Options: Accreditation Surveys May plans decline the accreditation status earned for a Full Survey?

Yes. A plan surveyed under the First Evaluation Option may decline the accreditation status (without penalty) at the completion of the survey, within 30 calendar days from receipt of its results. A plan that declines its accreditation status has the option to undergo a Follow-Up Survey within 12 months of receipt of its Full Survey results.

8.15.2012 Evaluation Options: Accreditation Surveys May a plan that was denied accreditation reapply for accreditation in less than a year from the date of the Denied status?

Yes, a plan may apply for a new Accreditation Survey (called an Expedited Survey) in less than a year under specific circumstances, including:

The plan was denied accreditation under the Interim Evaluation Option and may reapply after three months.

The organization demonstrates to NCQAs satisfaction that the issues identified in the original survey can be corrected within a six- to nine-month time frame as a result of the organizations activity.

Correction of the issues would raise the organizations accreditation status in a new survey.

To qualify for an Expedited Survey, a plan must submit a written request listing the steps it has taken to address the substantive issues that led to its Denied Accreditation status.

8.15.2012 Evaluation Options: Accreditation Surveys What is the Resurvey timeline for plans that score less than 85 percent of the possible points during the First Evaluation Option or the Renewal Evaluation Option?

A plan that scores less than 85 percent of the possible standards points must undergo a Resurvey within 12 months of the accreditation decision. The Resurvey look-back period is six months.

8.15.2012 Evaluation Options: Accreditation Surveys How soon will plans be able to earn accreditation for their Exchange product line?

NCQA-Accredited plans can earn accreditation for their Exchange product line as early as February 2013. Plans without previous NCQA Accreditation can apply for the Interim Evaluation Option as early as September 2012 and have their Exchange product line accredited as early as October 2013.

8.15.2012 Evaluation Options: Accreditation Surveys How do plans add an Exchange accreditation to an existing accreditation?

Plans submit an application identifying whether their Exchange product will be operated the same as the accredited product. If 70 percent of the Interim Evaluation Option elements are the same, the Exchange product line receives automatic accreditation under the plans accreditation. If the majority of the operations are not the same, plans undergo a streamlined Add-On Survey with a six-month look-back period.

8.15.2012 Evaluation Options: Status and Scoring Will currently accredited plans be scored 50 points for HEDIS/CAHPS and 50 points for standards?

No. Recalculation of accreditation scores is generally made against the HEDIS measures and point values in place at the time of the organizations last Full Survey.

8.15.2012 Evaluation Options: Status and Scoring How are plans scored that do not report HEDIS/CAHPS?

Standards-only accreditation scoring is based on 50 points.

8.15.2012 Evaluation Options: Standards and Guidelines To which product lines and evaluation options do the Member Connections (MEM) standards apply?

MEM standards apply only to commercial product lines for the First Evaluation Option and the Renewal Evaluation Option.