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.

Filter Results
  • Save

    Save your favorite pages and receive notifications whenever they’re updated.

    You will be prompted to log in to your NCQA account.

  • Email

    Share this page with a friend or colleague by Email.

    We do not share your information with third parties.

  • Print

    Print this page.

4.28.2020 COVID-19 If an organization opts not to report for HEDIS 2020, may it use its HEDIS 2019 (MY 2018) audited reportable hybrid rates when considering sample size reduction for HEDIS MY 2020 reporting?

Yes. Due to changes in reporting requirements because of COVID-19, organizations that do not report HEDIS 2020 results this year may use their audited HEDIS 2019 (MY 2018) reportable hybrid rates when considering sample size reduction rules for HEDIS MY 2020 reporting. In addition, if an organization is required to report their MY2019 administrative rate for HEDIS 2020, they will still be able to use their audited HEDIS 2019 (MY 2018) reportable hybrid rates when considering sample size reduction.


HEDIS 2020

4.27.2020 COVID-19 If an organization reports rotated hybrid rates for HEDIS 2020 (MY2019) (i.e., uses HEDIS 2019 (MY2018) hybrid rates), can the rotated rates be used when considering sample size reduction for HEDIS Measurement Year 2020 reporting?

Yes. The final reported hybrid rates for HEDIS 2020 (MY2019), regardless of rotation decision, can be used when applying sample size reduction rules for HEDIS MY2020 reporting.

HEDIS 2020

4.20.2020 COVID-19 Why isn’t NCQA using HEDIS and CAHPS for Accreditation scoring?

Although HEDIS/CAHPS results collected in 2020 reflect Measurement Year (MY) 2019, COVID-19 is impacting key aspects of HEDIS hybrid data collection and consumer experience nationally in 2020. The NCQA ratings methodology includes HEDIS/CAHPS measures and Accreditation status. While HEDIS/CAHPS reporting remains a required component of commercial and Medicaid Accreditation, we will not calculate an overall Health Plan Rating for MY 2019, because key aspects of data collection—especially consumer experience/CAHPS survey data—are understood to be compromised by the 2020 pandemic.
In addition to Accreditation, there are two components of Health Plan Ratings to consider when determining comparability for performance assessment: HEDIS and CAHPS results.

  1. HEDIS:
    1. Measures specified to use administrative data only: We expect HEDIS administrative measures to be less impacted; however, we are monitoring them closely. 
    2. Measures specified to use administrative data with a medical record review component (Hybrid Method): We expect some HEDIS hybrid measures to be compromised, given the challenge of accessing charts for abstraction.
  2. CAHPS: We have concerns about the validity of CAHPS results because the survey is being fielded this year from February–May, during the height of the pandemic as it continues to spread unevenly across the country, with wide regional variation.

Considerations: Preliminary impact modeling using MY 2018 data has shown that approximately half of all plans’ overall ratings would be affected if Hybrid measures and/or CAHPS survey results were excluded from Health Plan Ratings. Given the uncertainty and likely variability of COVID-19’s impact on hybrid data collection efforts and consumer experience, NCQA will not calculate ratings for comparison of plans in 2020 for MY 2019. Ratings based on a reduced set of measures would not be comparable to previous Health Plan Ratings.

In addition, since NCQA will align with CMS guidance (https://www.federalregister.gov/documents/2020/04/06/2020-06990/medicare-and-medicaid-programs-policy-and-regulatory-revisions-in-response-to-the-covid-19-public), we will not require Medicare Advantage plans to submit data for Accreditation. In order to maintain alignment across all product lines, we want to recognize commercial and Medicaid plans for collecting and reporting data; however, we understand that some plans’ ability to submit HEDIS/CAHPS data might be compromised. We will work with these plans individually.

HEDIS 2020

4.20.2020 COVID-19 What decision has NCQA made about Quality Compass for 2020?

CAHPS: CAHPS survey results will not be included in Quality Compass. We have concerns about the validity of CAHPS results because the survey is being fielded this year from February–May during the height of the pandemic as it continues to spread unevenly across the country, with wide regional variation.   

HEDIS: We will continually assess the feasibility of using the data reported to us for other purposes, including Quality Compass, provided data meet our usual standards for validity, accuracy and completeness. No public reporting will be done on any measures failing to meet such criteria. 

HEDIS 2020

4.20.2020 COVID-19 Why is NCQA requiring commercial and Medicaid Accredited plans to report HEDIS and CAHPS for Measurement Year 2019?

NCQA’s Health Plan Accreditation program consists of three components that together uniquely evaluate a plan’s infrastructure, consistency, quality and compliance. In addition to structure and process standards, NCQA also requires plans to have a robust framework for gathering, reporting, analyzing and acting on member experience (CAHPS) data and health outcomes (HEDIS) measures.

Although compliance with our standards is reviewed every three years, HEDIS/CAHPS reporting is assessed annually. This assessment is two-fold: We evaluate reporting compliance and capabilities and we calculate performance outcomes for benchmarking with other plans. While we will not calculate a performance outcome by way of our Health Plan Ratings in 2020, we will still assess whether plans are maintaining their reporting and quality infrastructure.

HEDIS 2020

4.16.2020 COVID-19 If a hybrid measure has multiple indicators that were reported using both the hybrid and administrative option for HEDIS 2019 (MY 2018), how do I report it this year if I’ve decided to rotate the measure? For example, I reported CDC hybrid last year, except for eye exam, which I reported administratively.

NCQA requires hybrid measures with multiple indicators to be reported using the same measurement year of data. Because of this requirement, if you report all CDC indicators hybrid last year (except for eye exam, which you reported administratively):

  • Rotate all CDC indicators and report the hybrid data for all CDC indicators you reported hybrid, and
  • Report eye exams using the MY 2018 administrative data.  

This is the only exception for using prior years’ administrative data.

HEDIS 2020

4.15.2020 Update: Practitioner Involvement and Adoption of UM Criteria For UM 2, Element A, factor 4, when an organization develops or adopts UM criteria, may it limit involvement of practitioners to practitioners who are organization staff, even if they are also network practitioners?

The answer posted in March 2020 unintentionally increased the rigor of the requirement for the 2020 standards year. Therefore, we are updating the answer.
For the 2020 standards year, organizations may limit involvement to practitioners who are staff or participants in the network; NCQA does not require non-staff network practitioners to be involved.

Effective for the 2021 standards year, organizations may not limit involvement to practitioners who are staff. Non-staff network practitioners must also be involved in developing, adopting and reviewing criteria, because they are subject to application of the criteria. If an organization has been unable to involve network practitioners, it must document its attempts and provide the documentation to NCQA during the survey.

This change will be released in the 2021 standards and guidelines.

MBHO 2020

4.15.2020 LTSS 1, Element G: HEDIS Measure The November 2019 Policy Update change to LTSS 1, Element G specifies that the Comprehensive Assessment and Update (LTSS-CAU) measure may be used instead of completing the file review. Is this correct?

No. Replace “LTSS-CAU” with “LTSS-CPU“ (Comprehensive Care Plan and Update). Performance results of LTSS-CPU may be used instead of completing the file review.

HP 2020

4.07.2020 TC 04 & QI 17 Can a large organization meet TC 04 and QI 17 through a shared Patient and Family Advisory Council (PFAC)?

Organizations may share a Patient and Family Advisory Council (PFAC) among sites as long as every site has representation on the council. Large organizations with many sites may consider creating multiple PFACs based on region or clinic type.

PCMH 2017

4.07.2020 CM 01 Could a chronic condition be considered under the high cost/high utilization category if it is expensive to treat?

The intent behind the high cost/high utilization category is that the practice is actively measuring the total cost of services or how much utilization occurs. A diagnosis of a condition may not be used as a proxy for high cost/high utilization. For instance, measuring the number of patients with uncontrolled asthma would not count under high cost/high utilization, but if those patients have multiple ER visits per year, this would be considered high utilization.


4.07.2020 TC 03 Would being connected to an HIE or RHIO meet the intent of TC 03?

No, connection to an HIE or RHIO alone would not meet the intent of TC 03. A PCMH collaborative activity must be external to practice, involve multiple practices, be ongoing (not a short-term activity), cover multiple aspects of patient-centered care, and involve some level of collaboration between practices to learn and share best practices with their peers. Connection to an HIE or RHIO may help the practice meet elective criterion CC21A.

PCMH 2017

4.07.2020 AC 04 For AC 04, must a practice report on calls during and after business hours?

Yes, to meet AC 04 a practice’s report must include calls received both during and after business hours. If the practice has different standard response time expectations during and after business hours, they may format this as two separate reports.

PCMH 2017