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.
No. Because the updates do not change measure intent, calculation logic, reporting requirements or audit expectations, NCQA does not anticipate an impact on performance results or historical trending. Organizations should continue reporting using the same processes they use today.
No. Organizations can continue using their current systems, reporting processes, workflows and operational practices. The updates do not introduce new reporting requirements or require changes to existing implementations. The updated structure is designed to help organizations that choose to pursue digital quality measurement in the future, while preserving current reporting expectations.
The specification structure updates do not change:
• Measure intent.
• Calculation logic.
• Reporting requirements.
• Data element reporting requirements.
• Audit expectations.
• Existing workflows and operational processes.
• Performance rates or trending assumptions.
Organizations can continue using the same codes, data sources, timing guidance, workflows and audit practices they rely on today.
Organizations may notice:
• More detailed descriptions of data sources.
• Terminology aligned with the FHIR® data model.
• Timing and status language that aligns with FHIR®-based digital measures.
• A connection between narrative specifications and digital measure specifications.
The updated structure is intended to help organizations understand how existing narrative specifications align with their digital equivalents. It is not intended to change reporting requirements for current HEDIS submissions.
NCQA is continuing its efforts to support organizations in the transition to digital quality measurement. The MY 2028 updates are non-substantive, structural changes to select narrative measure specifications. These updates create a connection between the narrative specification and its FHIR®-based digital equivalent while maintaining current reporting and audit practices. Organizations that are not pursuing Digital HEDIS can continue their current reporting approach without modification.
Organizations may not use PCS responses that are over 3 years old. Questions that relate directly to a measure specification or general guideline that was revised from a previous measurement year should be resubmitted rather than using the previous answer in PCS.
If the 1% calculation results in a decimal, round to the next whole number.
For example, a patient population of 1,440 results in 14.4 patients, the practice-site would report a minimum of 15 patients.
If a practice-site has a small patient population, they would also report to the next whole number. For example, if a practice-site has 62 patients (resulting in 0.62 for the CM 02 calculation), then they would report a minimum of 1 for CM 02.
Please note, beginning in 2027, the practice must identify at least 30 patients or 1% of the patient population, whichever is smaller.
Yes, changes to the Prenatal and Postpartum Care measure will be included in HEDIS MY 2027 Volume 2 (scheduled for release August 3, 2026). Consistent with the planned changes for maternity care billing, evaluation and management codes in combination with a TH modifier will meet criteria for prenatal and postpartum care. Codes no longer used for maternity care services will not be removed from the measure until the lookback period has passed. We anticipate additional codes may be added to the measure in the Technical Update release after CPT releases the full code set publication in the fall of 2026.
HbA1c results obtained from portable point-of-care devices are acceptable when the test is performed by clinical staff, regardless of whether the test is conducted at home or in a provider office. Self-collected samples are also acceptable if sent to a laboratory or provider’s office for analysis and result calculation. Self-administered tests reported by the member do not meet criteria (General Guideline: Self-Collected Samples).
For purposes of QI 2, Element C, behavioral health organizations include organizations that provide or manage behavioral health services, such as managed behavioral health organizations (MBHOs), inpatient psychiatric facilities and behavioral health clinics.
A hospital contract alone is not sufficient to meet the intent of the requirement because a hospital relationship may only provide limited, episodic data and may not reflect comprehensive data integration across the behavioral health continuum.
However, if the organization can demonstrate that the contracted entity provides behavioral health services beyond limited or episodic inpatient care and that the behavioral health data support assessment of care and outcomes for the behavioral health population, it may be considered a behavioral health organization for QI 2, Element C.
Applicable standards:
Both statements apply to UM decisions, but they reflect different review processes and therefore have different starting points for when assessing timeliness purposes.
Applicable standards:
