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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7.01.2025 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

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 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

6.16.2025 QI 3, Element A: Applicability of Behavioral Healthcare Reported Measures How can an organization that reports measures for QI 3, Element A meet the 50% threshold if behavioral healthcare services are carved out and the organization therefore has a “No Benefit” audit designation for 6 of the 10 measures? 

In this example, the organization may demonstrate compliance with QI 3, Element A by providing evidence that it reported 50% of required measures it is capable of reporting. The organization would be required to report a valid, numeric rate for at least 50% of the required nonbehavioral health measures (i.e., 2 of the 4).

HP 2025

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

6.16.2025 Clarifying the Definition of “Threshold Languages” How does NCQA define “threshold languages” for CM-LTSS Accreditation and LTSS Distinction in Health Plan Accreditation?

NCQA defines threshold languages as “all languages other than English spoken by 5% of the population or by 1,000 eligible individuals, whichever is less.” 

Applicable Standards: 

HP: LTSS 1, Element D, factor 2. 

CM-LTSS: LTSS 2, Element A, factor 2. 

CM-LTSS 2025

6.16.2025 Evidence for QI 3, Element D: Exchange Reporting What types of evidence may an organization submit to demonstrate reporting of the required measures for QI 3, Element D?

Organizations must provide an IDSS report and/or a CMS Proof Sheet as evidence of reporting the required measures for the Exchange product line in QI 3, Element D.

HP 2025

6.13.2025 TotalKnown Data Element for Language Diversity of Membership (LDM) Is the TotalKnown data element in Table LDM-A-1/2/3 and Table LDM-B-1/2/3 a calculated data element?

Yes. This data element is a calculated field in IDSS, and it should be shaded gray. We will correct this in the release of the MY 2026 Volume 2 Technical Specifications.

HEDIS 2025

6.13.2025 Direct reference code POS 81 for Adult Immunization Status (AIS-E) POS code 81 is included in the AIS-E measure specification but is not included in the Direct Reference Code tab of the VSD. Should the code be used when reporting Adult Immunization Status for MY 2025?

Yes. As described in Numerator 5—Immunization Status: Hepatitis B, use POS code 81 to exclude laboratory claims when identifying members with a history of hepatitis B illness. POS code 81 was mistakenly omitted from the Direct Reference Code tab of the VSD. Because the information needed for reporting is in the measure specification, NCQA does not intend to reissue the VSD.

HEDIS 2025

5.15.2025 Vaginal Specimen Source for the CCS and CCS-E measures Does an HPV or Pap test that has a vaginal sample source meet criteria for the numerator?

Yes. If the HPV or Pap test sample source is vaginal, and can be billed to an appropriate code in the value sets, it may be used to meet criteria.

HEDIS 2025

5.15.2025 Medication List in Deprescribing of Benzodiazepines in Older Adults (DBO) In the MY 2025 Medication List Directory, three codes (NDC codes 00378027701, 00378027705; RxNorm code 856792) are included in both the Chlordiazepoxide 10 MG Medications List and the Chlordiazepoxide 25 MG Medications List. Should the codes be included in both lists?

No. The codes are for “amitriptyline hydrochloride 25 MG/chlordiazepoxide 10 MG Oral Tablet.” They belong only in the Chlordiazepoxide 10 MG Medications List. NCQA re-released the MY 2025 Medication List directory on May 15, 2025, to incorporate this update. NCQA’s Measure Certification program confirmed that certification organizations deleted the codes from the Chlordiazepoxide 25 MG Medications List. No changes to the current process are necessary.

HEDIS 2025

5.15.2025 CAQH Application and Antidiscrimination Statement Has NCQA been in communication with CAQH about including the new NCQA requirements for race, ethnicity and language on its application?

Yes. NCQA has worked with CAQH to add a notice to its practitioner- and customer-facing provider credentialing applications, recognizing that discriminatory uses of race, ethnicity and language data are prohibited. CAQH is going live with the application update on 7/1/25.

The use of the CAQH application will be acceptable to meet CR 3, Element C, factor 6: Race, ethnicity and language in the 2025 Health Plan Accreditation standards and guidelines (and applicable products).

This applies to:
HPA: CR 3, Element A, factor 6
CRPN: CRA 3, Element A, factor 6, CRC 10, Elements A, factor 6
MBHO: CR 3, Element A, factor 6

HP 2025