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 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.

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

Standards-only accreditation scoring is based on 50 points.

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: 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.

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: 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: HEDIS Reporting and Scoring How does NCQA differentiate among plans that are accredited through the Renewal Evaluation Option and plans that are accredited through the First Evaluation Option but do not report HEDIS/CAHPS measures?

Plans that do not report HEDIS/CAHPS are capped at Accredited status. The list of plans that report HEDIS/CAHPS (or do not report) is available on NCQAs publicly reported Health Plan Report Card.

This applies to the following Programs and Years:

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.

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: Basics How are the First Evaluation Option and the Renewal Evaluation Option different?

The First Evaluation Option is for plans without existing NCQA Accreditation, and plans may, but are not required to report HEDIS/CAHPS until the third annual HEDIS reporting cycle. HEDIS/CAHPS reporting and scoring are required at the time of survey submission and annually thereafter for the Renewal Evaluation Option.

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: