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: 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: 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: Basics In what order do organizations progress through the Evaluation Options?

For the Interim Evaluation Option: Interim, to First, to Renewal.

For the First Evaluation Option: First to Renewal.

After a plan progresses to the Renewal Evaluation Option, all subsequent surveys will be for that Evaluation Option, unless the accreditation lapses for more than two years.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: HEDIS Reporting and Scoring Will NCQA review and score HEDIS/CAHPS measures if a plan submits them for the Interim Evaluation Option?

No. HEDIS/CAHPS results will not be used to evaluate plans seeking accreditation through the Interim Evaluation Option.

This applies to the following Programs and Years:

8.15.2012 Evaluation Options: Basics Which Evaluation Option should plans choose if they have not been accredited by NCQA?

Plans new to NCQA can earn accreditation through the Interim Evaluation Option or the First Evaluation Optionplans decide which Evaluation Option fits their needs. The two options give plans flexibility to choose based on their readiness and the comprehensiveness of their services.

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: 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 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 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: 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.

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: Standards and Guidelines CR 7: Recredentialing Verification was eliminated for Accreditation 2013. Is there a recredentialing requirement?

Yes. Verification requirements from CR 7 were merged into CR 3, Elements A_C.

This applies to the following Programs and Years: