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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8.12.2025 What do we do if a practice has to close temporarily or permanently?

Any structural or operational change must be reported to NCQA. Organizations must contact their NCQA Representative for further instructions within 30 days of the change.

PCMH

8.12.2025 Which clinicians need to be listed in Q-PASS?

Every qualifying clinician at a practice site is required to be listed in Q-PASS. Clinicians who meet the following three criteria must be listed for each Recognized PCMH site they practice at:

  1. MDs, DOs, PAs and APRNs (including nurse practitioners and clinical nurse specialists) who practice internal medicine, family medicine or pediatrics.
  2. The clinician can be selected by patients as their primary care clinician. 
  3. The clinician has their own or shares a patient panel.

PCMH

7.15.2025 Acceptable Titles for Reviewers The explanation for UM 9, Element D, factor 5 specifies that the reviewer's title is their position or role in the organization. How does the organization document this for external reviewers?

If a reviewer is external to the organization, the title/role must reflect it (e.g., “External Reviewer,” “External Independent Reviewer”). 

HP 2025

7.15.2025 Licensure Compact Arrangements Does NCQA require clinicians to be licensed in every state where they provide services to patients?

Yes. Applicable clinical staff must be licensed and verified in all states where they provide care to members. 

A licensure compact arrangement between states is acceptable if the clinician’s licensure was primary source verified in the clinician’s home state. NCQA reviews the compact agreement for evidence that the state (or states) accepts the home state’s license in lieu of state licensure. 

CM 2020

7.15.2025 Obtaining Sanction and Exclusion information from the State Agency Some State Medicaid agencies do not provide both sanction and exclusion information. What does NCQA expect in this situation?

The organization must provide documentation from the agency confirming that it does not provide sanction/exclusion information. If the state agency declines to supply written confirmation, the organization documents its effort to obtain the information.  

The organization must verify Medicaid sanctions and exclusions from one of the additional sources specified in the standards and guidelines. The credentialing file must include evidence of both the unavailability of the information from the state agency and verification from an approved additional source. 

Applicable Standards: 

HPA: CR 3, Element B; CR 5, Element A 

CRPN: CRA 4, Element B; CRA 5, Element A; CRC 9, Element A; CRC 12, Elements B and C 

MBHO: CR 3, Element B; CR 5, Element A 

HP 2025

7.15.2025 Deduplication of Mammography Episodes on the Same Date of Service for Documented Assessment After Mammogram (DBM-E) If there is more than one eligible mammography episode on the same date of service, does that count as a single denominator event?

It is up to the organization to ensure that multiple mammograph episodes are the same event if they occur on the same date of service. HEDIS measure certification assumes events on the same day are different mammograms. If evidence shows the mammography episodes are the same, count only one. Organizations should develop their own methods and apply them consistently when reporting.

HEDIS 2025

7.15.2025 Multiple BIRADS assessments for Follow-Up After Abnormal Mammogram Assessment (FMA-E) Can one follow-up event meet criteria for multiple BIRADS assessments?

Yes. One follow-up event may meet criteria for multiple BIRADS assessments. Each BIRADS assessment counts as separate denominator events, and requires the appropriate follow-up to count toward the numerator. However, one breast biopsy may meet criteria for multiple high-risk BIRADS assessments, and one mammogram or ultrasound may meet criteria for multiple inconclusive BIRADS assessments.

HEDIS 2025

7.15.2025 Multiple BIRADS Assessments for Documented Assessment After Mammogram (DBM-E) If multiple distinct mammograms are identified on the same date of service, does a single BI-RADS score within 14 days of each mammogram make the member compliant for all mammograms?

No. Each mammogram requires a unique BIRADS assessment (e.g., two mammograms need two separate BIRADS to meet numerator criteria). A single documented BIRADS assessment dated on or within 14 days (15 days total) of multiple mammography episodes does not meet criteria for multiple denominator events.

DBM-E sample and test decks have been updated and re-posted. If you already received a status of “pass” for a DBM-E test deck, the status has been re-set and you must run the updated deck to certify. The deadline to certify the measure will be extended to July 31 so organizations can accommodate this update.

HEDIS 2025

7.01.2025 What are the new elective criteria that have been added to the PCMH Standards and Guidelines for Version 11?

Best Practices from NCQA’s Virtual Primary Care Program to PCMH:
The following elective criteria were written during the creation process of the new Virtual Care program, but found to be best practice for all primary care settings. For this reason, nine new elective criteria are added to the PCMH program.
 

Criteria Criteria Title Brief Description
TC 10 Patient Consent The organization requests patient consent to treatment through virtual modalities.
KM 30 Prescribing Patterns The organization tracks medication prescribing practices and performs analysis on prescribing patterns.
KM 31 Interpreter Services The organization uses competent interpreter or bilingual services to communicate with individuals in a language other than English.
KM 32 Virtual Care Training The organization provides staff training on relevant clinical and nonclinical topics.
AC 15 Appropriate Modality of Care The organization has a process for determining that virtual care is appropriate for the patient.
AC16 Information for Appeals The organization provides clinical information in response to appeals of denials based on medical necessity or treatment guidelines.
AC 17 Services Covered by Insurance The organization has a process for informing patients which services are covered by insurance.
QI 20 Assessment of Clinician and Care Team Experience The organization assesses clinician and care team experience for delivering care.
QI 21 Goals and Actions to Improve Clinician and Care Team Experiences The organization identifies at least one opportunity to improve the clinician and care team’s experience, implements an intervention and measures the intervention’s effectiveness.

PCMH 2017

7.01.2025 What are the cadence thresholds that have been added to the PCMH Standards and Guidelines for Version 11?

Cadence Thresholds Added:
Cadence thresholds are applied to 45 criteria to ensure continuous improvement and to avoid stagnation in workflows (i.e. “at least annually").
 

Criteria Title
TC 06: Individual Patient Care Meetings/ Communication
TC 07: Staff Involvement in Quality Improvement
KM 02: Comprehensive Health Assessment
KM 03: Depression Screening
KM 04: Behavioral Health Screenings
KM 05: Oral Health Assessment
KM 06: Predominant Conditions
KM 07: Social Determinants of Health
KM 09: Diversity
KM 11: Population Needs
B. Educates practice staff on health literacy and
C. Educates practice staff in cultural competence.
KM 17: Medication Responses and Barriers
KM 21: Community Resource Needs
KM 23: Oral Health Education
KM 26: Community Resource List
KM 27: Community Resource Assessment
AC 01: Access Needs and Preferences
AC 09: Equity of Access
AC 11: Patient Visits with Clinician/Team
AC 13: Panel Size Review and Management
AC 14: External Panel Review and Reconciliation
CM 01: Identifying Patients for Care Management
CM 02: Monitoring Patients for Care Management
CM 03: Comprehensive Risk Stratification
CM 04: Person-Centered Care Plans
CM 05: Written Care Plans
CM 06: Patient Preferences and Goals
CM 07: Patient Barriers to Goals
CM 08: Self-Management Plan
CM 10: Person-Centered Outcomes Approach
CM 11: PCO: Monitoring and Follow-Up
CC 06: Commonly Used Specialists Identification
CC 07: Performance Information for Specialist Referrals
CC 14: Identifying Unplanned Hospital and ED Visits
QI 03: Appointment Availability Assessment
QI 04: Patient Experience Feedback
QI 05: Health Disparities Assessment
QI 07: Vulnerable Patient Feedback
QI 08: Goals and Actions to Improve Clinical Quality Measures
QI 09: Goals and Actions to Improve Resource Stewardship
QI 10: Goals and Actions to Improve Appointment Availability
QI 11: Goals and Actions to Improve Patient Experience
QI 13: Goals and Actions to Improve Disparities in Care/ Service
QI 15: Reporting Performance Within the Practice
QI 16: Reporting Performance Publicly or With Patients
QI 17: Patient/Family/ Caregiver Involvement in Quality Improvement

PCMH 2017

7.01.2025 What changes were made to the PCMH Standards and Guidelines for Version 11?

KM 02: Comprehensive Health Assessment Added a note, "All patients need all the components addressed in their medical record. Providing components from multiple patients does not meet the intent."​
KM 03: Depression Screening Added this clarification in the adolescent section, "Screening under age 12 may be conducted as clinically indicated."​
KM 14: Medication Reconciliation and
KM 15: Medication Lists		 The thresholds have changed from more than 80% to more than 90%.
KM 26: Community Lists Added, “The practice maintains a list of resources supported by the community and/or payers by selecting five topics or service areas of importance to the patient population.”
AC 01: Access Needs and Preferences Added more detailed information, “The practice annually surveys patients to determine if existing access (e.g., days open, hours of operation, modalities, etc.) is meeting the needs of the patient population. The screening also collects input of the patient to understand their preferences.”
CM 04: Person-Centered Care Plans Clarified that the required elements include the patient’s medication list and management as well as the patient’s comprehensive problem list.
Also, provided more guidance on a care plan’s requirements.
CM 10: Person-Centered Outcomes Approach Added, “If the organization chooses to use PROMs to track goals, NCQA recommends that the organization have at least 8–10 PROMs for clinicians to choose from, for use with patients.”
CC 04: Referral Management Added, “The practice uses the patient's medical health history and clinical protocols to determine when a referral is necessary.”
Also, “The organization confirms that referrals are local to the patient's community of residence, and whether the referral is in the patient's practitioner network.”
Additionally, “The expectation is that the specialist/ancillary clinician return visit documentation so the loop can be closed”
CC 08: Specialist Referral Expectations
And CC 09: Behavioral Health Referral Expectations		 Added, “The organization communicates referral expectations to patients, including the contact information of the referring clinician and additional instructions or education, if applicable.”
CC 21: External Electronic Exchange of Information Added D. Clinical data exchange with payers.
This is worth 1 elective credit point.
QI 01: Clinical Quality Measures and
QI 02: Resource Stewardship Measures		 Added a documented process to the evidence.
Cadance Thresholds Please see additional FAQ for cadence thresholds, added to 45 existing criteria.

Criteria Retirement:
Eight criteria were identified as no longer serving a substantial purpose or adding meaningful value to primary care, leading to their retirement from the PCMH program.

Criteria Identification and Title
TC 03: External PCMH Collaborations
TC 09: Medical Home Information
KM 08: Patient Materials
KM 18: Controlled Substance Review
KM 25: School/Intervention Agency Engagement
KM 28: Case Conferences
CC 12: Co-Management Arrangements
QI 18: Electronic Submission of Measures

PCMH 2017

6.16.2025 Conducting Audit of Effectiveness Quarterly If an organization chooses to complete its audit and analysis for the Information Integrity requirements quarterly, may it also complete the audit of effectiveness quarterly?

Yes. Organizations that choose to conduct their audit and analysis for Information Integrity more frequently than annually (i.e., quarterly), may also conduct the follow-up audit of effectiveness more frequently. The audit must be within the 3–6 month time frame prescribed by NCQA. 

Applicable Standards: 

HP: CR 8, Element C; CR 8, Element D, factor 2. UM 12, Element D, UM 12, Element E, factor 2; UM 12, Element F, UM 12, Element G, factor 2. 

CRPN: CR 2, Element C, CR 2, Element D, factor 2. 

MBHO: CR 8, Element C; CR 8, Element D, factor 2. UM 11, Element D, UM 11, Element E, factor 2; UM 11, Element F, UM 11, Element G, factor 2. 

HP 2025