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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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10.15.2019 CR 2, Element A, Factor 1 What is the required composition of the Credentialing Committee?

NCQA does not require a Credentialing Committee size, composition or quorum beyond that the committee must include practitioners who participate in the network.
Participating practitioners on the credentialing committee must be from a range of specialties or departments that represent the types of practitioners reviewed by the committee. For example, it would not be sufficient for only primary care practitioners to participate on the committee unless the network has only primary care practitioners.

HP 2020

10.15.2019 PHM 5: Assessment and Evaluation Does a combined summary of all factors in the assessment meet the requirement for documenting the conclusion of the initial assessment for PHM 5, Elements D and E?

Yes. Assessment and evaluation each require a case manager or a qualified individual to draw and document a conclusion about the data or information collected. Raw data or answers to questions do not meet the requirement; there must be a documented summary of the meaning or implications to the member’s situation, so data can be used in the case management plan.
The organization must draw a conclusion for each factor (unless otherwise stated in the explanation). This may be in separate summaries for each factor or in a combined summary, or in a combination of these.

CM 2019

10.11.2019 QI 08 - QI 14 Why are the QI Worksheet and the reports for QI 08 – QI 14 not eligible for virtual review?

Reports submitted for QI often outline a lot of information (baseline performance, goals, actions, and remeasurements) that must be carefully reviewed. By uploading the documents ahead of the virtual review, it gives the Evaluator time to review the data and note areas for clarification.
 

PCMH

9.16.2019 Cutoff Date for NDCs in the HEDIS 2020 MLD What is the cutoff date for including National Drug Codes (NDCs) in the HEDIS 2020 Medication List Directory (MLD)?

Any NDC or RxNorm code that is in the U.S. National Library of Medicine’s RxNorm database as of September 1, 2019 will be considered for inclusion in the HEDIS 2020 MLD, which will be posted to the NCQA website on November 1, 2019. This is a change from past years’ cutoff date, which was September 30.

HEDIS 2020

8.15.2019 Scoring UM File Review workbook for UM 5 timeliness Requirements Since UM 5, Elements A, C and E decision timeliness requirements were retired for 2020, how will the file review workbook be completed for those elements for 2019?

Because of the complexities of the workbook formulas, we are unable to change the workbook to accept “NA” in time for 2019 Standards Year surveys. To correctly calculate the notification date scoring, a date must be entered in this field.
NCQA will not require organizations to provide documentation of the decision date and will instruct surveyors to enter the earliest of

  1. The written notification date(s), or
  2. The verbal notification date(s) (if applicable).

Regardless of the score calculated for decision date,

  1. Surveyors will not score 30 files for this factor (although if it is necessary to review 30 files for the notification date, surveyors may need to complete this field, as described above for additional files).
  2. Surveyors will score the element NA in IRT.

HP 2019

8.15.2019 UM 5 Timeliness Requirements The UM 5, Elements A, C, E timeliness requirements were retired in 2020 Health Plan Accreditation. These requirements will be scored NA in HPA 2019. How will this affect timeliness reporting in UM 5, Element G?

An “NA” score for UM 5, Elements, A, C and E will not affect the review of UM 5, Element G: UM Timeliness Report. However, NCQA still requires organizations to monitor and submit a report of timeliness of decision making and notification of decisions for UM 5, Element G.

HP 2019

8.15.2019 Scoring UM 5 Timeliness Requirements The UM 5, Elements A, C, E timeliness requirements were retired in 2020 Health Plan Accreditation. These requirements will be scored NA in HPA 2019. Does that mean that the “Explanation” and the “Related information” sections of these elements regarding notifications no longer apply to UM 5, Elements B, D and F?

No. The “Explanation” and the “Related information” sections of UM 5, Elements A, C and E still apply to UM 5, Elements B, D and F, respectively. All applicable information was moved to the relevant elements for HPA 2020.

HP 2019

8.15.2019 Documentation for ME 5, Element C and ME 6, Element C Will NCQA review an organization’s policies and procedures for ME 5, Element C and ME 6, Element C?

For ME 5, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s most recent assessment and actions reports completed at least once during the look-back period. 

Similarly, for ME 6, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s annual evaluation report and improvement of identified deficiencies.

HP 2020

8.15.2019 Documentation for MEM 2, Element C and MEM 3, Element C Will NCQA review an organization’s policies and procedures for MEM 2, Element C and MEM 3, Element C?

For MEM 2, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s most recent assessment and actions reports completed at least once during the look-back period.
Similarly, for MEM 3, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s annual evaluation report and improvement of identified deficiencies.

HP 2019

8.15.2019 Policy Update regarding must-pass elements and the status modifier “Under Corrective Action” NCQA posted an update for PHP 2019, CVO/HIP/WHP/DM 2016 and PHQ 2013 that stated, “If an organization does not meet the must-pass threshold for any must-pass element, a status modifier of ‘Under Corrective Action’ will be displayed after the applicable accreditation status (e.g., Accredited/Certified—Under Corrective Action) until NCQA confirms that the organization has completed the Corrective Action Plan (CAP).” Is NCQA changing the policy for these products, which has been that if an organization fails to meet the must-pass threshold, it is denied Accreditation or Certification?

No. This policy update was made in error and will be corrected in November 2019 for the products listed. An organization will be denied Accreditation or Certification if it fails to meet the must-pass threshold for specified requirements in those products.

DM 2013

7.15.2019 QI 04B Would a Patient Family Advisory Council (PFAC) be acceptable as qualitative feedback for QI 04B?

The evidence must specifically reflect the practice’s patient population. Standalone practices whose PFAC only includes patients and family members from the practice may use it to meet QI 04B. For practices that are a part of an organization with other primary care practices under the same umbrella, a shared PFAC would not meet QI 04B. While an organization with a shared PFAC in most cases cannot use it as evidence for QI 04B, it may be used it to demonstrate shared evidence to meet elective criteria TC 04 (2 credits) and QI 17 (2 credits).

PCMH 2017

5.07.2019 QI 08 & AR QI 03 Would increasing survey response rate qualify as a measure for improving patient experience ( QI 11, AR QI 03)?

No, increasing survey response rate is important in obtaining more representative patient feedback, but would not meet the intent of QI 08 or AR QI 03. The response rate is part of the platform for obtaining the feedback, while the measure for these criteria should be improving the feedback itself.
 

PCMH 2017