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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5.15.2022 UM and CR Advanced System Controls—Policies and Procedures Are organizations that provide evidence of “advanced system controls” eligible to receive Met for UM 12, Elements A and C, and for CR 1, Element C?

No. If the organization provides evidence of advanced system controls capabilities, it must submit policies and procedures for UM 12, Elements A and C and for CR 1, Element C. Policies and procedures must address all factors regarding advanced system control capabilities.

Organizations are only eligible to receive a score of Met for UM 12, Elements B and D, and for CR 1, Element D if they provide evidence of advanced system control capabilities that both automatically record dates and prevent changes that do not meet the organization’s policies and procedures.

This applies to the following Programs and Years:
HP 2022|UM-CR-PN 2022

5.15.2022 System Control Requirements Review by Product Line If auditing is used to monitor an organization’s system controls or a delegate’s system controls, is sampling by product line required?

No. Sampling is not required by product line if the product lines are managed the same (a single system is used to manage all product lines).

This applies to the following Programs and Years:
HP 2022|MBHO 2022|UM-CR-PN 2022

5.15.2022 System Controls Goal for Analysis Is a goal required for system controls monitoring analysis for UM 12, Elements B and D, factor 2 and CR 1, Element D, factor 2?

No. Although the organization may set a monitoring goal, NCQA does not require it for UM 12, Elements B and D, factor 2 and CR 1, Element D, factor 2. The intent is that the organization reviews all instances of modifications that did not meet its policies and procedures.

This applies to the following Programs and Years:
HP 2022|UM-CR-PN 2022

4.15.2022 Data Aggregator Validation (DAV) Data for ECDS Reporting Can validated DAV data streams be used for ECDS reporting? If yes, how should they be categorized (which SSoR)?

Yes. If validated DAV streams are used, they should be categorized as HIE/clinical registry data sources.

This applies to the following Programs and Years:
HEDIS MY 2022, 2021

4.15.2022 Data Aggregator Validation (DAV) Data for ECDS Reporting Can validated DAV data streams be used for ECDS reporting? If yes, how should they be categorized (which SSoR)?

Yes. If validated DAV streams are used, they should be categorized as HIE/clinical registry data sources.

This applies to the following Programs and Years:
HEDIS MY 2022

4.15.2022 Initiation and Engagement of Substance Use Disorder Treatment (IET) Should denominator episodes be deduplicated to one per day? For example, if a member has two outpatient visits with an SUD diagnosis on the same date of service (with different providers), is it one denominator episode or two?

Deduplicate denominator episodes to one per day. Two eligible SUD encounters on the same date of service count as one denominator episode.  

This applies to the following Programs and Years:
HEDIS MY 2022

4.01.2022 Why do I need to provide more information for a low denominator or rate if there is no minimum requirement?

It is to ensure patient safety and routine implementation of medical home activities. Depending on the population served and/or the reporting period, a small denominator is unexpected and may indicate issues (e.g., with data, documentation, implementation). Providing additional information allows the practice to explain—beyond the numbers—when performance is outside the expected range.

This applies to the following Programs and Years:
PCMH 2017

4.01.2022 Is there a minimum denominator requirement when reporting a rate for Annual Reporting?

No. There is no minimum denominator requirement. A sample of 30 (or more, because this increases the reliability of the sample) is expected to ensure statistical soundness, but there may be cases where it may be appropriate for the denominator to be <30. NCQA requests practices enter an explanation in the Notes from the Organization section in QPASS in this case.

If a practice reports a denominator <30 without a note, the evaluator may contact the practice to confirm data accuracy and to understand the data. The evaluation will be returned to the practice so they can enter an explanation in the Notes from the Organization section for the cited criteria.

This applies to the following Programs and Years:
PCMH 2017

3.28.2022 RAND Table for LTSS MY 2022 For LTSS MY 2022 reporting, the random number for sampling members for the Long-Term Services and Supports Shared Care Plan With Primary Care Practitioner (LTSS-SCP) is “0.59”; it is “0.58” for Long-Term Services and Supports Comprehensive Assessment and Update (LTSS-CAU) and Long-Term Services and Supports Comprehensive Care Plan and Update (LTSS-CPU). Should all three measures have the same RAND?

Yes. The RAND should be “0.58” for LTSS-SCP, LTSS-CAU and LTSS-CPU for HEDIS LTSS MY 2022 reporting.

This applies to the following Programs and Years:
HEDIS-LTSS MY

3.15.2022 Inaccessibility of practitioners’ licensure information from Maryland Department of Health The Maryland Department of Health (MDH) experienced a network security incident on December 4, 2021, that made its network systems and practitioners’ licensing information inaccessible for primary source verification. The MDH reports that all disrupted licensing board systems were restored as of February 4, 2022. The MDH granted a grace period (with no expiration date) on practitioners’ licenses set to expire between November 2021 and February 2022, and issued temporary licenses to affected practitioners whose licenses will expire June 2022.

How will NCQA evaluate affected practitioners’ files?

For Maryland practitioners credentialed between December 2021 and February 2022, NCQA will not penalize organizations on inability to verify licensure due to the MDH network security incident. NCQA accepts the MDH’s grace period on licensure expirations and accepts temporary licenses issued by the MDH and will consider them current and valid. Organizations should adhere to guidance provided by MDH and document the guidance in the affected practitioners’ credentialing files.

This applies to the following Programs and Years:
HP 2022|MBHO 2022|UM-CR-PN 2022|CVO 2022

2.15.2022 Annual Monitoring of UM System Controls Monitoring for Delegates Have the allowed methods to audit delegate files in UM 13, Element C, factor 5 changed?

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

  • 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
  • The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

This applies to the following Programs and Years:
HP 2022|MBHO 2022|UM-CR-PN 2022

2.15.2022 MBHO: Annual Monitoring of UM System Controls Monitoring for Delegates Have the allowed methods to audit delegate files in UM 12, Element C, factor 5 changed?

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

  • 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
  • The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

This applies to the following Programs and Years:
MBHO 2022