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: 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: 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: 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: 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 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: 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:

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 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 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 Evaluation Options: Eligibility How long must a plan be in operation before applying for NCQA Accreditation?

Plans may apply for the Interim Evaluation Option and the First Evaluation Option at any time, regardless of how long they have been in operation.

For the Interim Evaluation Option, plans must show evidence that they met the requirements before the survey start date.

For the First Evaluation Option, plans must show that they met the requirements for the six months before their survey date.

This applies to the following Programs and Years:

7.16.2012 Initiation and Engagement of Alcohol and Other Drug DependenceTreatment In the Initiation of AOD Treatment indicator, the third paragraph states that if the Index Episode was an outpatient, intensive outpatient, partial hospitalization, detoxification or ED visit, the member must have an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization with an AOD diagnosis, within 14 days of the IESD (inclusive). What does "inclusive" mean?

"Inclusive" means the IESD is day 1 in the 14-day count for the Initiation of AOD Treatment indicator. The time frame for initiation is the IESD and the next 13 days, for a total of 14 days. For example, if a members IESD was an outpatient visit on August 1, the initiation visit must occur on or between August 1 through August 14.

This applies to the following Programs and Years:
HEDIS 2013