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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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1.15.2025 Verification of Licensure Does a clinician who is licensed to practice in multiple states need to be verified in each state?

For CM 7, Element E, organizations must verify the license of clinical staff only in states where they provide services to patients.

CM 2020

1.15.2025 2025 Information Integrity Standard Changes and Delegation Do organizations need to conduct a delegation audit(s) on the 2025 Information Integrity standards within 12 months prior to survey submission date?

Yes, organizations must conduct a delegation audit within 12 months of the survey submission date.

For example, an organization with a Renewal Survey on July 1, 2025, will be surveyed on the 2025 standards, and will be expected to audit its delegates on CR 9, Element C, factors 5–7 in HPA/MBHO (CR 3, Element C, factors 5-7 in CRPN) at least once in the prior year (between July 2024 and the July survey submission date).

HP 2025

12.16.2024 NPDB Acceptable Source for Medicare and Medicaid Exclusions Is the NPDB an acceptable source for Medicare and Medicaid exclusions?

Yes. The NPDB is an acceptable source for both Medicare and Medicaid exclusions.

For Medicaid, organizations must obtain exclusion information from the state Medicaid agency, in addition to either of the following sources:

  • NPDB, or
  • List of Excluded Individuals and Entities maintained by OIG and available over the internet).

For Medicare, organizations may obtain exclusion information from any of the NCQA acceptable sources.

HP 2025

12.16.2024 Sources for Medicare Sanctions Are organizations required to verify Medicare sanctions from all of the following sources?
• AMA Physician Master File.
• FSMB.
• NPDB.
• SAM.gov.

No. The requirement is that organizations verify Medicare sanctions from any of those sources, but there is no requirement to verify sanctions from all of them. 

HP 2025

12.16.2024 MMP Plans CMS intends to dissolve Medicare-Medicaid Plan (MMP) contracts in 2026. Will that change product line rules for Accreditation?

No. Plans that are responsible for both the Medicare and Medicaid components for dual-eligible members may select Medicare, Medicaid, or both, for Accreditation purposes. 

HP 2025

12.16.2024 Reviewer Names on Denial and Appeal Notifications Does NCQA require names or signatures of the reviewers on UM denial and appeal notifications?

No. NCQA does not require names or signatures of the reviewers on UM denial and appeal notifications. Please refer to UM 4, Element C and UM 9, Element D for documentation requirements.

HP 2025

12.13.2024 Advance Notice of RAND Table Changes for HEDIS MY 2025 How is NCQA changing the release of RAND numbers for HEDIS reporting beginning in MY 2025?

NCQA will remove the RAND table from the Guidelines for Calculations and Sampling with the release of the HEDIS MY 2025 Technical Update on March 31, 2025. Future releases of the HEDIS Volume 2: Technical Specifications for Health Plans publication will not contain a RAND table.

Beginning MY 2025, NCQA will use an alternative timeline and approach to distribute RAND numbers for HEDIS reporting. This information will be released in the NCQA store for purchasers of HEDIS Volume 2 in the November before production of systematic samples for hybrid reporting (e.g., November 2025, for MY 2025).  

Organizations participating in NCQA’s Measure Certification program will receive separate guidance on how NCQA will accommodate this change for certification of systematic sampling logic.

HEDIS 2025

11.15.2024 Inconsistency with Member-Reported Services Requirements What are common themes in data containing member-reported services that suggest noncompliance with HEDIS requirements and should not be used?

Common themes include:

  • Clinical accountability for the information.
    An arrangement may exist where a provider, such as a PharmD, interacts with members to collect information on their last colorectal cancer screening or breast cancer screening. It is unclear if a PharmD has the appropriate clinical training to document the complete context of the service or interpret the information being shared. Nor is it evident that a PharmD would be clinically accountable for that aspect of the member’s care (preventive cancer care).

Another arrangement that may exist includes workflows where providers (e.g., NPs, PAs) contact a plan’s membership annually to assess a member’s medical history, including when they received their last cancer screenings. It is unclear if a singular touchpoint by the NP/PA indicates that the provider has clinical accountability for the member’s care. Organizations are not allowed to call members to collect data.

  • Including and maintaining information in the health record.
    A member’s health record should be accessible to the member and the care team responsible for that aspect of their care. Systems that are internal-facing only to a plan do not represent a source of data that contribute to an individual’s ongoing clinical care. Further, an individual’s health record should be available to them to reference or share with a care team in the future.

HEDIS 2025

11.15.2024 Verification of Medicare and Medicaid Sanctions and Exclusions Are organizations only required to verify Medicare and Medicaid sanctions and exclusions for practitioners who only provide services for members in the organization’s Medicare and Medicaid product lines?

No. Verification of sanctions and exclusions are not product line–specific requirements. For each practitioner in the scope of credentialing, the organization must verify Medicare and Medicaid sanctions regardless of the product line for which practitioners are contracted.

HP 2025

11.15.2024 Guidance in Volume 2 for Member-Reported Services What guidance in HEDIS Volume 2 can be referenced to determine if member-reported services data can be used?

HEDIS Volume 2 provides guidance in several places:

  • Member-reported services and biometric values general guideline.
    This general guideline states that member-reported services may be used only if collected by a primary care practitioner or specialist (if the specialist is providing a primary care service related to the condition being assessed, in the course of taking a member’s history), and if the information is included in the member’s health record.
  • Supplemental data general guideline.
    Information on services reported by members often reside in non-standard supplemental sources. The supplemental data general guideline states that there must be evidence of provider accountability for the information documented. The guideline also states that documentation of member-reported services must be complete (e.g., date, place of service, procedure, prescription, test result or finding, practitioner type).
  • Electronic Clinical Data Systems general guidelines.
    Organizations may develop workflows that result in documentation of member-reported services. A common example is documentation in systems identified as case management. The ECDS general guideline states that case management systems are shared, meaning that there is bidirectional access to the data. These data would be accessible to members and to members’ care teams for care coordination and planning.

HEDIS 2025

11.15.2024 Implementation Plans for Health Equity Will the implementation plan deadlines be extended for the 2024 Health Equity Accreditation and Health Equity Accreditation Plus products? 

Yes. For Initial Surveys scheduled on or between July 1, 2024, and June 30, 2026, the organization may submit a detailed implementation plan that includes a timeline as evidence for applicable factors.  

 

Implementation plans may be submitted for Initial Surveys for the following requirements until June 30, 2026: 

 

  • HE 2, Element A. 

  • HE 2, Element D. 

  • HE 2, Element E. 

  • HE 2, Element G. 

  • HE Plus 3, Element C. 

  • HE Plus 5, Element B. 

  • HE Plus 5, Element E. 

HEA 2024

11.15.2024 Gold-Standard Example for Member-Reported Services What’s a scenario that reflects the intent of NCQA’s requirements for member-reported services?

Example: During a new-patient office visit, the patient reports receiving a colonoscopy in the previous year to their primary care provider. During the discussion, the provider documents the details (when and where the procedure occurred, findings) in the office visit progress notes in the patient’s EHR.

This example represents the intent behind the HEDIS guidelines because:

  • The provider collecting the information has the appropriate clinical experience to interpret what the patient is sharing and assumes clinical accountability for that aspect of the patient’s clinical care.
  • The provider documents the colonoscopy in the patient’s medical record allowing it to be accessible to other care team providers and to the member for clinical decision making.

HEDIS 2025