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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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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: Basics Must NCQA-Accredited plans go through the Renewal Evaluation Option?

Yes. To maintain its accreditation, an NCQA-Accredited plan must go through the Renewal Evaluation Option.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: Standards and Guidelines Several elements in the First Evaluation Option require annual evaluation, even though the Evaluation Option has a six-month look-back period for all other elements. How do plans meet this annual requirement?

NCQA will expand the look-back period if it is necessary for plans to demonstrate that performance requirements are met and to produce an adequate sample for file reviews. For annual requirements, plans must complete the activity at least once during the prior year.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: Survey Process Will NCQA conduct onsite surveys (at the health plan) for the Interim Evaluation Option?

No. NCQA conducts onsite surveys for the First and Renewal Evaluation Options, but not for the Interim Evaluation Option.

This applies to the following Programs and Years:

8.15.2012 UPDATED: 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 submitted on or after November 1, 2012, are not included in file review for any element in UM 9.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: Basics For which Evaluation Options are organizations eligible if their accreditation has expired?

A plan whose accreditation status has expired or has been withdrawn for less than two years is eligible for the Renewal Evaluation Option with a 24-month look-back period.

A plan whose accreditation expired more than two years ago is eligible for accreditation through the Interim Evaluation Option or First Evaluation Options with a six-month look-back period.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: HEDIS Reporting and Scoring Plans that are not scored on HEDIS/CAHPS are capped at Accredited status. Will NCQA grandfather plans that earned Commendable status but were not scored on HEDIS/CAHPS?

Yes. The Commendable status will remain valid until the plans existing accreditation status expires.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years: