FAQ Directory

Yes. For the 2026 standard year only (surveys conducted between July 1, 2026, and June 30, 2027), NCQA will allow organizations to submit a detailed implementation plan.

The plan must include: 

• A description of actions to make UM criteria available electronically at the point of care.
• A timeline for implementation on or before June 30, 2027.

Look-Back Period: Effective immediately, the look-back period for the entire Element B for First Surveys and Renewal Surveys has changed from six months to “prior to the survey date.” 

This approach provides flexibility and additional time for organizations to meet requirements.

Applicable Standards:

• Health Plan Accreditation: UM 2, Element B.
• Behavioral Health Accreditation: UM 2, Element B.
• UM Accreditation: UM 4, Element B.

This applies to the following Programs and Years:

Yes. Data from UM delegates must be included in the UM denial and appeal rates reported for UM 1, Elements B-E (in Health Plan Accreditation). The intent of reporting the rates for these elements is to provide a comprehensive view of the organization’s UM denial and appeal rates. Therefore, the expectation is that the organization presents all rates in a single workbook, rather than separating requests received by the organization (e.g., health plan) and those received by the delegate.

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. C-CDA documents cannot be used for these purposes as the documents are electronically generated and not the same as the medical record documented in the primary source system where care was originally recorded (e.g. electronic medical record). This includes C-CDA documents received from HIEs.

HIEs support the exchange of clinical information, an important function for the delivery of care. Organizations are encouraged to use electronic files received from an HIE, such as electronic C-CDA or FHIR documents (e.g., C-CDA XML, FHIR JSON), as a supplemental data source.

This applies to the following Programs and Years:

NCQA currently maintains prior year HPR scores on NCQA’s HPR Final Results website.

You can also purchase the Health Plan Ratings in Excel Format file which lists plan’s overall rating, composite, subcomposite and measure-level scores from the NCQA store. 

This applies to the following Programs and Years:

For AR-KM 3 (2026 Annual Reporting) the threshold will remain at more than 80% with the intent that practices will begin implementing updated workflows to be able to reach more than 90% by Annual Reporting in 2027.

For PCMH, a transition of care is defined as: A patient’s movement from one care setting (e.g., hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another. That said, medication review and reconciliation should occur at transitions of care, or at least annually. If a patient has experienced multiple transitions of care within the reporting period (e.g. hospital discharge, post cardiology visit, hospital discharge, post gastroenterology visit) they should be counted in the denominator for each transition of care.
 

This applies to the following Programs and Years:

NCQA will give organizations credit (an individual measure rating of “5”) if both reported Direct Race and Direct Ethnicity is ≥20%. Organizations that do not report Direct Race and Direct Ethnicity ≥20% will receive an individual measure rating of “0”. The measure has a weight of 1.0. 

This applies to the following Programs and Years:

To calculate individual measure scores, NCQA truncates final raw rates and percentiles to 3 decimals and compares the rates submitted by plans to The National All Lines of Business 10th, 33.33rd, 66.67th and 90th measure benchmarks and percentiles, and then assigns the individual measure rating (calculated as whole numbers on a 1–5 scale) that the plans receive for each measure as follows:

5 = plans with a rate ≥ 90^th percentile (top 10% of plans)

4 = plans in the top third but not in the top decile (66.67^th percentile ≤ rate < 90^th percentile)

3 = the middle one-third of plans or (33.33^rd percentile ≤ rate < 66.67^th percentile)

2 = plans above the bottom 10% of plans but in the bottom one-third of plans (10^th percentile ≤ rate < 33.33^rd percentile)

1 = plans with a rate < 10^th percentile (in the bottom 10% of plans)

This applies to the following Programs and Years:

Yes. Plans that are non-numerically rated (Partial Data Reported, No Data Reported, Low Enrollment) still need to review all other plan-related information (e.g., Legal Name, State Coverage, NCQA Accreditation status) to ensure its accuracy.

This applies to the following Programs and Years:

NCQA will give organizations credit (an individual measure rating of “5”) if the reported “Total Known” Preferred Written Language and “Total Known” Preferred Spoken Language is ≥20%. Organizations that do not report “Total Known” Preferred Written Language and “Total Known” Preferred Spoken Language ≥20% will receive an individual measure rating of “0”. The measure has a weight of 1.0.

This applies to the following Programs and Years:

We use your Accreditation status as of the last business day in June of the release year  for display purposes and to calculate bonus points. If a plan has an NCQA status modifier (e.g., Under Review by NCQA, Under Corrective Action, Merger Review in Process, Appealed by Organization) as of the last business day in June of the release year, it will be appended to the Accreditation status.

Display options during the Plan Confirmation, Projected Ratings and Final Ratings releases are: Yes; Yes (Interim); Yes (Provisional); Yes – CAP; Yes – APEAL; Yes (Interim) – CAP; Yes (Provisional) – CAP; Yes (Provisional) – APEAL; Yes – Merger Review in Process; Yes – Under Review by NCQA; Yes (Interim) – Under Review by NCQA; Yes (Provisional) – Under Review by NCQA; No; No (In Process); No (Scheduled); No (Suspended); No (Revoked).

Accreditation status display options for the public release of the Ratings on NCQA's Health Plan Report Card website on September 15 are: Accredited; Not Accredited; Accredited – Interim; Accredited – Provisional; Accredited – Under Review by NCQA; Under Corrective Action; Scheduled; In Process; Expired; Denied; Suspended; Revoked; Accredited – Appealed by Organization; Accredited – Merger Review in Process.

This applies to the following Programs and Years:

AR-KM 1: Problem Lists
NCQA recognizes that the upload requirements for AR-KM 1 (2026) require entering either a numerator, denominator and reporting period OR an uploaded list of top priority conditions and concerns. One of these evidence options will be left blank. This criterion only requires one of the two evidence fields listed to be completed.

AR-AC 2: Appointments Outside Business Hours
AR-AC 2 (2026) requires a Documented Process and Evidence Upload. If extended hours are provided at the practice site, the organization does NOT need to provide a Documented Process. To satisfy the minimum upload requirements in Q-PASS, please create a file (word, PDF, etc.) that indicates that extended hours are provided at the practice site.

AR-CM 3: Person-Centered Care Plans
For AR-2026, all five categories of care management are listed within the Q-PASS upload. You will only upload evidence into 3 of the 5 categories provided, based off of your organization’s care management efforts.  The reason for this reformat is to help evaluators more easily identify what a care plan is managing, as often patients may fall into multiple categories based on diagnoses listed on the care plan. Identifying what CM category the patient is being care managed for helps us eliminate unnecessary back and forth with practices as much as possible. Please note that AR-CM 3 is a site-specific criterion, so each practice-site will need to complete this AR upload. It is acceptable for practice-sites within the same organization to have differing categories that are care managed, as patient populations differ.
 

This applies to the following Programs and Years:

Health Plan Ratings is not where you make your public reporting selection because that occurs in NCQA’s Interactive Data Submission System (IDSS). Please contact your NCQA Account Manager if you have questions about IDSS or public reporting.

This applies to the following Programs and Years: