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: 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.

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: HEDIS Reporting and Scoring Are HEDIS/CAHPS measures reported during the third annual HEDIS reporting cycle scored for the First Evaluation Option?

No, unless a plan opts for HEDIS/CAHPS scoring.

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: 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 Which Evaluation Option should plans with New Health Plan accreditation apply for next?

Plans with NHP accreditation must apply for the Renewal Evaluation Option with a 12-month look-back period.

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 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: 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: 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 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: