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: 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:

8.15.2012 Evaluation Options: HEDIS Reporting and Scoring When must plans report HEDIS/CAHPS measures if they are going through the First Evaluation Option?

Plans report HEDIS/CAHPS measures during the third annual HEDIS reporting cycle of their accreditation status. For example, if an organization receives a status in September 2014, it must submit audited HEDIS/CAHPS results in June 2017.

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 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: 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 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: 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: 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: 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:

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: 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: 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: