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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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.

This applies to the following Programs and Years:
PCMH 2017

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).

This applies to the following Programs and Years:
CVO 2022|CM 2020|CM-LTSS 2020|WHP 2020|PHP 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).

This applies to the following Programs and Years:
HP 2023|MBHO 2023|UM-CR-PN 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.

This applies to the following Programs and Years:
Exchange MY 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

This applies to the following Programs and Years:
HP 2022, 2023|UM-CR-PN 2022, 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

This applies to the following Programs and Years:
MBHO 2022, 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.

This applies to the following Programs and Years:
Exchange MY 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.

This applies to the following Programs and Years:
CVO 2022|CM 2020|CM-LTSS 2020|HP 2023|MBHO 2023|UM-CR-PN 2023

4.24.2023 Multiple Health Plan Ratings for One Product in a State How is it possible for plans to have multiple ratings for one product within a given state?

Plans can have multiple ratings for one product within the same state because they might have certain state or contractual submission requirements that fall outside of the combined submission requisite that they send to NCQA for Accreditation purposes. Therefore, this results in plans submitting one combined submission (required) for Accreditation and then they still elect to select other submissions for state or other contractual obligations, which NCQA includes as part of its Ratings program.

This applies to the following Programs and Years:

4.14.2023 Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) Should the Follow-Up on Positive Screen numerator include the 12-17 years age stratification?

Yes. The 12-17 years age stratification is reported for the Follow-Up on Positive Screen numerator and should be added to the age stratification on page 240 of MY 2023 HEDIS for QRS Version.

This applies to the following Programs and Years:
Exchange MY 2023

2.16.2023 Diabetes Measures* Should patients who have not been diagnosed with diabetes but take diabetes medications for off-label use (e.g., weight loss, heart failure) be excluded from the diabetes measures?

For measures with hybrid reporting methodology (HBD, BPD, EED), members who have not had a diagnosis of diabetes but receive diabetes medications for conditions other than diabetes (e.g., weight loss, heart failure) may be identified as valid data errors and replaced with a member from the oversample.
To meet criteria for a valid data error for these measures, the medical record must contain no evidence of diabetes and must contain evidence to substantiate the data error (how the member wound up in the measure, why it is incorrect). It is expected that the medical record will not contain evidence of diabetes, and will contain documentation that the patient is on the medication, and why. This documentation, in combination with no other documentation of diabetes in the medical record, meets criteria for a valid data error. Valid data errors are subject to review by the auditor.
Valid data errors work for the Hybrid Method only because medical record data are used to ensure that the member does not have diabetes. For the administrative method, these members remain in the measure as medical records are considered supplemental data that may not be used for identifying valid data errors, or when reporting the HBD, BPD and EED measures using the administrative method, or the KED, SMD, EDH and SPD measures, which are administrative-only measures.
We are working to refine the diabetes denominator related to off-label medication use. The next annual HEDIS public comment period is planned for February–March 2023, but organizations may submit comments on any measure, at any time, through PCS (you do not need to wait until February).

*This FAQ applies to the following measures: Hemoglobin A1c Control for Patients With Diabetes (HBD), Blood Pressure Control for Patients With Diabetes (BPD), Eye Exam for Patients With Diabetes (EED), Kidney Health Evaluation for Patients With Diabetes (KED), Statin Therapy for Patients With Diabetes (SPD), Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD), and Emergency Department Visits for Hypoglycemia in Older Adults With Diabetes (EDH)

This applies to the following Programs and Years:
HEDIS MY 2023, 2022

2.15.2023 CM: Use of software for evidence-based clinical guidelines for CM 4, Element A For CM 4, Element A, factor 1, is it considered delegation if an organization uses evidenced-based clinical content licensed for use in their own case management system?

No. The use of another entity’s evidence-based content within the organization’s case management system is not considered delegation if the organization maintains control over how the content is used and can customize it as needed. The evidence used to support the content must be cited.

This applies to the following Programs and Years:
CM 2020