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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7.17.2023 Use of software to collect credentialing information (API) May an organization use an application program interface (API) that retrieves data directly from a primary or approved source, even though it is not a web crawler?

Yes. Organizations may use an API to access data from a primary or approved source, and must provide documentation that the API collects information only from primary or approved sources.

Organizations that use an API must still meet the “Appropriate documentation” requirements in CR 1, Element A, including documentation that the organization's staff reviewed the information.

As noted in an FAQ from February 15, 2023, use of another entity’s software to collect credentialing information is not considered delegation unless the entity also reviews the information on the organization’s behalf.

HP 2023

6.23.2023 July 2023 PCMH Summary of Updates What changes were made to the PCMH Standards and Guidelines for Version 9?

Topic	Update Highlights
Front Matter (Audit Section)	Added “Evidence of implementation submitted for an audit, including reporting data, must be recent to the time of the audit.”
Front Matter	Added a section addressing conflicts with regulatory requirements. This applies to all Recognition products.
CM 04	Added: “Note: After-visit summaries may only be used if they contain plain language and show patient involvement in the plan’s creation.” Also added, “The care plan is written at a health literacy level accessible to the patient (i.e., does not contain medical jargon, abbreviations/acronyms or billing codes).”
KM 09	Removed “pronouns” and “language” in the guidance section as an example of “other aspects of health”.
KM 09	Added a clarification about evidence, “Practices are to submit a report that is broken down by numerator/denominator and percentages for each category. For example, Black or African American = 400/1000 (40%); Asian = 300/1000 (30%), etc."
AC 01	Added to the guidance: The key to this criterion is patient preference. Some examples of questions asked may include, but are not limited to: • Our practice is considering extended hours to 7PM. What day of the week would you most prefer? • Our practice offers same day appointments at 9AM each day. Does this time work for your same day needs? Yes/No with a follow-up question: If not, please identify a time that you prefer. • If scheduled telehealth visits were offered, would you use them instead of an in-person office visit? (Y/N or Likert Scale). Can follow-up with options.
CM 11	New criterion – Person-Driven Outcomes Approach: Monitoring and Follow-Up
QI 01 and 02	Clarified that beginning in 2024, standardized measures must be used and reporting through the Measures Reporting Tile in Q-PASS.

PCMH 2017

6.23.2023 July 2023 PCSP Summary of Updates What changes were made to the PCSP Standards and Guidelines for Version 6?

Topic	Update Highlights
Front Matter (Audit Section)	Evidence of implementation submitted for an audit, including reporting data, must be recent to the time of the audit.
Front Matter	Added a section addressing conflicts with regulatory requirements. This applies to all Recognition products.
CM 04	Added: “The care plan needs to be written in a health literacy level accessible to the patient (not medical jargon or billing codes).” Also added – “Note: After-visit summaries may only be used if it contains plain language and shows patient involvement in the creation of the plan.”
KM 06	Removed “pronouns” and added “language” in the guidance section as examples that may not be submitted for “other aspects of health”.
KM 09	Added clarification on evidence: “Practices are to submit a report that is broken down by numerator/denominator and percentages for each category. For example, Black or African American = 400/1000 (40%); Asian = 300/1000 (30%), etc.”
PM 20	New criterion – Person-Driven Outcomes Approach: Monitoring and Follow-Up

PCSP 2019

6.15.2023 Use of Delegate's Self-Service Portal for Delegation Reporting Is it acceptable for organizations to pull reports from a delegate’s system for the delegation agreement reporting requirement?

Yes, if the delegation agreement addresses the required information in the Explanation (e.g., CR 8, Element A, factor 3 for credentialing). The delegation agreement must specify:

How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
What information is reported by the delegate in the delegate's system about the delegated activities.
How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).

HP 2023

6.15.2023 Use of a Delegate's Self-Service Portal for Delegation Reporting Is it acceptable for organizations to pull reports from a delegate’s system for the delegation agreement reporting requirement?

Yes, if the delegation agreement addresses the required information in the Explanation. The delegation agreement must specify:

How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
What information is reported by the delegate in the delegate's system about the delegated activities.
How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).

CVO 2023

5.15.2023 Colorectal Cancer Screening (COL-E) Should the Colorectal Cancer Screening-E (COL-E) age stratification be updated?

Yes. Replace the reference to “46-49” with “46-50,” and replace the reference to “50-75” with “51-75” in the age stratification and in Table COL-E-A-4: Data Elements for Colorectal Cancer Screening.

Exchange 2023

5.15.2023 Applicable Standards for Mail Service Organizations Considered Delegates What standards are considered a delegation relationship if an organization uses a mail service organization to meet the distribution requirements?

NCQA considers the following standards to be a delegation relationship if an organization uses a mail service organization to meet the distribution requirements:

NET 4, Element A: Notification of Termination
NET 4, Element B: Continued Access to Practitioners
UM 5, Elements A, B, C: Timeliness of UM Decisions
UM 7, Elements B, C, E, F, H, I: Denial Notices
UM 9, Elements B, D: Appropriate Handling of Appeals
UM 11, Element B: Pharmaceutical Restrictions/Preferences
UM 11, Element C: Pharmaceutical Patient Safety Issues

HP 2023

5.15.2023 MBHO: Applicable Standards for Mail Service Organizations Considered Delegates What standards are considered a delegation relationship if an organization uses a mail service organization to meet the distribution requirements?

NCQA considers the following standards to be a delegation relationship if an organization uses a mail service organization to meet the distribution requirements:

CC 3, Element A: Notification of Termination
CC 3, Element B: Continued Access to Practitioners
UM 5, Element A: Timeliness of UM Decisions
UM 7, Elements B, C: Denial Notices
UM 9, Elements B, D: Appropriate Handling of Appeals

MBHO 2023

5.15.2023 Social Need Screening and Intervention (SNS-E) Should the SNS-E measure include exclusion criteria for Medicare members?

No. There are no Medicare member exclusions. Remove the second bullet from Exclusion 1, which reads:

Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
- Enrolled in an Institutional SNP (I-SNP) any time during the measurement period.
- Living long-term in an institution any time during the measurement period, as identified by the LTI flag in the Monthly Membership Detail Data File. Use the run date of the file to determine if a member had an LTI flag during the measurement period.

Exchange 2023

5.15.2023 Definition of Annual Does NCQA’s definition of “annual” allow for a 2-month grace period?

As noted in the Glossary appendix, NCQA’s long-standing definition of “annual” is 12 months plus a 2-month grace period (12–14 months). “Grace period” refers to allowing organizations to complete an activity after it is due and not before it is due.

CVO 2023

4.24.2023 Health Plan Ratings Data for Scoring What data is 2022 HPR using to score plans?

Commercial: MY 2021 HEDIS and CAHPS submitted to NCQA by June 2022
Medicaid: MY 2021 HEDIS and CAHPS submitted to NCQA by June 2022
Medicare: MY 2021 HEDIS, MY 2020 CAHPS and HOS

HPR 2022

4.24.2023 Health Plan Ratings Overview How do the Ratings work, in brief?

NCQA’s HPR overall rating is the weighted average of a plan's HEDIS, CAHPS and HOS (Medicare only) measure ratings, plus Accreditation bonus points (if the plan is Accredited by NCQA), rounded to the nearest half point displayed as Stars. Dozens of measures are calculated on a 0–5 scale in half-points (5 is highest) by comparing the plan submitted rate to The National All Lines of Business 10th, 33.33rd, 66.67th and 90th measure benchmarks.

HPR