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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5.15.2024 Use of AI for UM Decisions May organizations use artificial intelligence to make medical necessity denial decisions or appeal decisions?

No. NCQA UM standards do not allow the use of AI to make medical necessity denial decisions, or any appeal decisions. 

If an organization uses AI in the UM process, medical necessity review requires that denial decisions be made only by an appropriate clinical professional and appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.  

UM-CR-PN 2024

4.15.2024 SNS-E Numerator Criteria for Completed Screenings For screening indicators, which responses to screening questions meet numerator criteria?

Any coded response (i.e., any non-null response—positive or negative) on a pre-specified instrument for food, housing and transportation counts for completed screening numerators (numerators 1, 3, 5). The PRAPARE Food Insecurity Instrument question (LOINC code 93031-3) is an exception. Based on how the question is structured and responses are coded, a “No” or “None of the above” response cannot be coded and must be left null. Therefore, a null response meets criteria for this item only. 

HEDIS 2024

3.18.2024 HEDIS MY 2023 Audit Timeline Modifications Does the recent guidance issued by NCQA on HEDIS MY 2023 audit timeline modifications apply to all organizations?

No. If the medical record review retrieval and/or abstraction operations for HEDIS MY 2023 reporting of your organization were not impacted by the Change Healthcare cyberattack, then the timeline modifications do not apply to you. You must follow the HEDIS MY 2023 Audit Timeline published on NCQA.org.
Affected organizations (defined above) should work with their auditor on HEDIS MY 2023 timeline modifications. All HEDIS Compliance Audit Licensed Organizations will share this information with the relevant organizations.


HEDIS 2023

3.15.2024 New Consensus-Based Entity for Performance Measurement Since the National Quality Forum (NQF) is no longer the consensus-based entity for CMS, what source can we use to identify standardized measures?

Battelle replaced NQF as the consensus-based entity for CMS; the Battelle Partnership for Quality Measurement (PQM) Submission Tool and Repository Measure Database can be found here: https://p4qm.org/. Organizations may only use measures classified as “Endorsed."

MBHO 2013

3.08.2024 Are providers required to sign-off on care plans?

The request for provider sign-off stems from the ability to verify work has been reviewed by the eligible clinician, and not solely managed by another role within the organization—or externally.

An eligible provider must be able to provide evidence of their involvement in Care Management efforts. They should not be submitting care management efforts they have not directly reviewed. That said, we suggest provider’s sign-off on care plans to indicate that they have reviewed the care plans they are counting towards their CM efforts. 

If there is a systematic limitation–meaning an electronic system does not allow the provider to electronically sign-off on the care plan–an acceptable workaround would be to provide a relevant office visit note(s), a telephone communication note(s), etc. where the provider has documented that the care plan was reviewed, discussed, updated, etc. with the patient. 

Evidence provided should exemplify that the eligible clinician has had direct oversight in care management efforts for the patient. Care planning efforts may be facilitated by other parties within the practice, but the eligible clinician must be an involved participant in the care management efforts included in their CM reporting.

PCMH 2017

2.21.2024 KM 09 Is there a minimum percent threshold for KM 09 (diversity) reporting?

The expectation is that diversity data is collected from all patients in the practice. An overwhelming majority of the practice’s population should have diversity data on file. If this is not the case, the practice should annotate an implementation plan in the notes section of Q-PASS. This plan should include an expected timeline for improved performance.

Please note that diversity data should be collected directly from the patient/family/caregiver. Please refer to the Standards and Guidelines for acceptable response options for each aspect of diversity.

PCMH 2017

2.21.2024 AR-CM 1 (AR 2024) What is considered “total population” for AR-CM 1 (AR 2024)?

For AR-CM 1 (AR 2024), “total population” is defined as unique patients seen by the practice in the prior 12 months. The intent of this attestation is to provide a point of reference for the ratio of care managed patients to your practice-site’s total patient population.

PCMH 2017

2.15.2024 Indication of an FOBT Test for the Colorectal Cancer Screening Measure Is documentation of “Colon Screening,” “Colon Screen” or “Colorectal Cancer Screening” sufficient to be considered an FOBT if it was completed during the measurement year?

Yes. Documentation of “Colon Screening,” “Colon Screen” or “Colorectal Cancer Screening,” with screening dates during the measurement year, could indicate an FOBT, the least invasive test that would use this limited documentation.

HEDIS 2023

2.15.2024 Compliant Documentation of Colonoscopy for the Colorectal Cancer Screening Measure Is documentation of “c-scope," “colo” or “colon” sufficient to be considered a colonoscopy?

No. Documentation of “c-scope,” “colo” or “colon” alone is not specific enough to be considered evidence of a colonoscopy.

HEDIS 2023

2.15.2024 Use of Continuity of Care Documents (CCDs) Can CCDs from health information exchanges be used for medical record review?

No. The medical record review process for the hybrid data collection methodology requires that information be abstracted from the medical record. CCDs are not the same as the medical record; this includes CCDs received from health information exchanges. Note that because electronically exchanged CCDs may be used as supplemental data, they are subject to supplemental data requirements.

HEDIS 2024

2.15.2024 Provider Interaction with Admission/Discharge Information in the Medical Record for the Transitions of Care Measure For the Notification of Inpatient Admission and Receipt of Discharge Information indicators, is evidence that the provider reviewed the admission/discharge information required (i.e., is the provider required to sign or acknowledge the admission/discharge information after it is filed in the outpatient medical record)?

No. Evidence that the PCP or ongoing care provider reviewed the admission/discharge information is not required for these indicators. If the required information is filed in the outpatient medical record or shared EMR (accessible to the PCP or ongoing care provider) during the required time frame, this alone meets criteria.

HEDIS 2024

2.15.2024 ADT Feeds for the Transitions of Care Measure Does an admission notification documented in an ADT feed meet criteria for the Notification of Inpatient Admission and Receipt of Discharge Information indicators?

No. Admission/discharge notifications in the ADT alone do not meet criteria (even if the provider has access to the ADT) because ADTs are not considered the legal medical record.
Criteria are met if the provider documents ADT notifications in the appropriate outpatient medical record or shared EMR (accessible to the PCP or ongoing care provider) during the time frame specified in the measure.

HEDIS 2024