FAQ Directory

No. At this time, these tests are not included in the COL-E measure or its value sets and we cannot predict if or when sRNA type tests will be added.

NCQA relies on a broad body of scientific evidence and guidance from multiple independent clinical guideline bodies when developing and updating quality measures. These include, but are not limited to, recommendations from the U.S. Preventive Services Task Force (USPSTF), as well as other national organizations. NCQA monitors emerging screening concepts and reviews evidence as it becomes available through its established measure development processes.

Because of this, while some tests may receive FDA authorization and are covered under certain CMS policies, they are not automatically included in our measures. NCQA will continue to review the guidelines and scientific literature, and communicate changes if they are made.

This applies to the following Programs and Years:

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: 

• Health Plan Accreditation – QI 2, Element C. 

This applies to the following Programs and Years:

Both statements apply to UM decisions, but they reflect different review processes and therefore have different starting points for when assessing timeliness purposes. 

• Statement 1 applies when the organization receives a UM request. Timeliness is measured from the date the request is received from the member or the member’s authorized representative. 
• Statement 2 applies to subsequent reviews of previously approved urgent concurrent care when the organization has procedures for conducting ongoing reviews. In these cases, no new request is submitted. Because the organization initiates the review based on its established procedures, timeliness is measured from the date the ongoing review is conducted. 

Applicable standards: 

• Health Plan Accreditation – UM 5, Elements A-C. 
• Behavioral Health Accreditation – UM 5, Element A. 
• Utilization Management Accreditation – UMA 1, Element B; UMA 2, Element B; and UMA 3, Element B.

This applies to the following Programs and Years:

Reporting by SSoR category (e.g., EMR, HIE, case management, administrative) was sunset for MY 2026 and measure results no longer need to be attributed to an SSoR category when reported.

Additionally, HEDIS MY 2026 does not include guidance on hierarchy for ECDS reported measures. The hierarchy should not change the performance result, just the data source contributing the information.

NCQA is not prescriptive about how source prioritization is programmed into the measure logic. It is up to the plan to determine how sources are prioritized when calculating results to avoid double counting and it should be done consistently across measures.

This applies to the following Programs and Years:

NCQA is introducing a new optional tier-based multi-site sampling approach for Person-Centered Care Plans to reduce Annual Reporting burden for larger organizations.

Organizations requesting multi-site sampling should submit requests through My.NCQA at least six months prior to the reporting date. For the initial rollout, NCQA will allow some flexibility and encourages organizations to submit requests as soon as possible prior to their reporting date. Beginning January 1, 2027, all requests should be submitted at least six months in advance of the reporting date. NCQA will review submitted requests and provide the sampled subset of sites back to the organization.

Organizations that would like to align the reporting dates of some, or all, of their sites should submit the request along with their multi-site sampling request, through My.NCQA. 

 Who is eligible:

• Organizations with 9 or more sites.
• Sites must share the same reporting date.

What this means:

• Eligible organizations may submit care plans from a subset of sites selected by NCQA
• Sampling is based on organization size.
• Upload 3 de-identified care plans for managed care patients per sampled site.
• Submitted care plans must represent 3 of the 5 care plan categories listed in CM 01: Identifying Patients for Care Management.

Note: This option applies to written care plans only. Practices must still report the number of patients who have a care plan per site.

If you are interested in using this option or would like to confirm eligibility, please contact your NCQA Representative via My.NCQA.
 

This applies to the following Programs and Years:

This applies to the following Programs and Years:

This applies to the following Programs and Years:

For PHM 2, Element B, factor 4 the organization must assess the needs of members with serious mental illness (SMI) and assess the needs of members with serious emotional disturbance (SED). If a member has both conditions, separate assessments are not required under factor 4. The organization determines if the member is assessed as a member with SMI or SED.

Applicable standards: 
•    Health Plan Accreditation – PHM 2, Element B
•    Behavioral Health Accreditation – PHM 2, Element B

This applies to the following Programs and Years:

UM approval and denial rates are calculated at the request level, not at the service or code level. A request is counted once in the denominator, regardless of how many services it includes. If any part of the request is approved, it counts as 1 approval. If any part is denied, it counts as 1 denial. Therefore, a partially approved and partially denied request is included in both the approval and denial rates.

For example, if one authorization request includes three CPT codes and one is approved while two are denied, the organization counts:

• 1 approval decision (count in the approval rate numerator),
• 1 denial decision (count in the denial rate numerator),
• 1 authorization request (count once in the approval and denial denominator).

As another example, if an organization made decisions on 300,000 total authorization requests, and:

• 200,000 were completely approved,
• 50,000 were partially approved/denied, and
• 50,000 were completely denied,

the rates would be calculated as follows:

• Overall approval rate: ((200,000 + 50,000) / 300,000) x 100 = 83%.
• Overall denial rate: ((50,000 + 50,000) / 300,000) x 100 = 33%.

The overall approval rate cannot exceed 100%, and the overall denial rate cannot exceed 100%. However, if an organization sums these two rates, the combined total may exceed 100%.

Applicable standards:

• Health Plan Accreditation – UM 1, Elements B-E
• Behavioral Health Accreditation – UM 1, Elements B-D
• Utilization Management Accreditation – UM 3, Elements B-E

This applies to the following Programs and Years:

No. To align with HPA, NCQA does not review communication to practitioners about the availability of UM criteria in UM 4, Element B in UM Accreditation or BHA. Instead, NCQA evaluates whether the organization makes the criteria available electronically (e.g., through an EHR, portal, or website). Acceptable evidence includes system reports or screenshots demonstrating how practitioners access the criteria at the point of care.

Applicable standards:

• Utilization Management Accreditation – UM 4, Element B
• Behavioral Health Accreditation – UM 2, Element B

This applies to the following Programs and Years:

The stem for HO 2, Element D should read as follows: "The organization's methods for evaluating member or patient disability status include:" 
Note: Although the stem appears in the e-publication version of the standards, it is not visible in the IRT version of the standards. This will be updated in the IRT version in August 2026.

Applicable standards:

• Health Outcomes and Community-Focused Care Accreditation – HO 2, Element D

This applies to the following Programs and Years:

• 20 are fully overturned, and
• 10 are partially overturned.

• Health Plan Accreditation – UM 1, Element E
• Behavioral Health Accreditation – UM 1, Element C
• Utilization Management Accreditation – UM 3, Element E
  

This applies to the following Programs and Years: