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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8.25.2023 Change to AR 2023 Criteria - AR TC 1 and AR CC 1 What changes have been made to Annual Reporting 2023?

There has been an update to the PCMH 2023 annual reporting requirements. AR TC 1 ( Staff Involvement in Quality Improvement) and AR CC 1 ( Hospital and ED Coordination) will now require additional documentation to demonstrate practices are meeting requirements. NCQA is requesting a documented process and evidence of implementation in addition to attestation for this criteria. All practices will have the ability to upload necessary documentation in Q-PASS by the end August. Until then, your RP manager may reach out to request additional documents.
 

PCMH 2017

8.16.2023 Required Exclusions and Hybrid Reporting For HEDIS MY 2023, optional exclusions are now required exclusions. For hybrid measures, if a member meets exclusion criteria via medical record review, can the member be removed from the measure and replaced with a member of the oversample?

Yes. If medical records document that the member meets exclusion criteria, the member is excluded from the sample and replaced with a member of the oversample.
 

HEDIS 2023

8.16.2023 Kidney Health Evaluation for Patients With Diabetes (KED) What is the intent of removing LOINC code 32294-1 from the Urine Albumin Creatinine Ratio Lab Test Value Set?

The KED measure provides actionable information for chronic kidney disease identification and management. General guidance from our experts is that tests included in the measure should align with guideline recommendations from the American Diabetes Association and the National Kidney Foundation. For this reason, only quantitative uACR tests are allowed and semi-quantitative tests are not considered measure compliant. Removing LOINC code 32294-1 from the value set maintains these coding parameters.

HEDIS 2024

8.16.2023 PCS Questions Do answers from the Policy Clarification Support system have an expiration date?

Organizations cannot use PCS responses that are over 3 years old. If your question relates directly to a measure specification or general guideline that was revised from a previous measurement year, submit the question rather than using the answer in PCS.

HEDIS 2024

8.15.2023 Lack of present illegal drug use Does NCQA require practitioners to attest to their lack of present and past illegal drug use?

NCQA requires practitioners to attest to their lack of present illegal drug use, but not to past drug use or history of drug use.

Organizations are not required to refer exclusively to the present; therefore, an organization may choose to ask about both present and past drug use.

CVO 2023

7.27.2023 Cervical Cancer Screening (CCS) In HEDIS MY 2023, the CCS exclusion for hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix is now a required exclusion. Does documentation of a hysterectomy in combination with documentation that the patient no longer needs Pap testing/cervical cancer screening sufficient to meet criteria as a required exclusion for HEDIS MY 2023 reporting?

No. Members with documentation of “hysterectomy” and documentation indicating that they no longer need Pap testing/cervical cancer screening must remain in the measure for MY 2023 reporting. Members with documentation of a “vaginal pap smear” and documentation of “hysterectomy” must also remain in the measure for HEDIS MY 2023 reporting. This is because the documentation must match the clinical specificity of the codes in the value sets and there are no codes that are clinically synonymous with these examples.
There must be evidence of a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix in order to meet required exclusion criteria for MY 2023 reporting.
Documented “vaginal hysterectomy” or “complete/total/radical hysterectomy” that matches a definition in applicable value sets may be used to meet criteria, subject to auditor approval.
 

HEDIS 2023

7.17.2023 UM 5, Elements A-C: Notifying the Practitioner If an organization receives a request from a provider rather than a practitioner (for example, a lab or DME company), may the organization address the UM denial notification to the provider without also notifying the attending or treating practitioner as well?

No. Only addressing the UM denial notification to the provider does not meet the intent of the requirement. The UM denial notification must also be addressed to the attending/treating practitioner.

If information on the attending/treating practitioner was not provided with the request, the organization attempts to identify the practitioner and documents its efforts to identify the practitioner. If the organization is not able to obtain the name of the attending/treating practitioner, the practitioner’s name is not required. In such a case, the organization must address the notification "To the Attention of the Attending/Treating Practitioner.”

For urgent concurrent decisions, the organization may inform the hospital Utilization Review department staff without attempting to identify the attending/treating practitioner, with the understanding that staff will inform the practitioner.

In all cases, if the practitioner is not known, the organization must address the notification “To the Attention of the Attending/Treating Practitioner”; the practitioner’s name is not required.

UM-CR-PN 2023

7.17.2023 UM 5, Element A: Notifying the Practitioner If an organization receives a request from a provider rather than a practitioner (for example, a lab or DME company), may the organization address the UM denial notification to the provider without also notifying the attending or treating practitioner as well?

No. Only addressing the UM denial notification to the provider does not meet the intent of the requirement. The UM denial notification must also be addressed to the attending/treating practitioner.

If information on the attending/treating practitioner was not provided with the request, the organization attempts to identify the practitioner and documents its efforts to identify the practitioner. If the organization is not able to obtain the name of the attending/treating practitioner, the practitioner’s name is not required. In such a case, the organization must address the notification "To the Attention of the Attending/Treating Practitioner.”

For urgent concurrent decisions, the organization may inform the hospital Utilization Review department staff without attempting to identify the attending/treating practitioner, with the understanding that staff will inform the practitioner.

In all cases, if the practitioner is not known, the organization must address the notification “To the Attention of the Attending/Treating Practitioner”; the practitioner’s name is not required.

MBHO 2023

7.17.2023 Use of software to collect credentialing information (API) May an organization use an application program interface (API) that retrieves data directly from a primary or approved source, even though it is not a web crawler?

Yes. Organizations may use an API to access data from a primary or approved source, and must provide documentation that the API collects information only from primary or approved sources.

Organizations that use an API must still meet the “Appropriate documentation” requirements in CR 1, Element A, including documentation that the organization's staff reviewed the information.

As noted in an FAQ from February 15, 2023, use of another entity’s software to collect credentialing information is not considered delegation unless the entity also reviews the information on the organization’s behalf.

UM-CR-PN 2023

7.17.2023 CVO: Use of software to collect credentialing information (API) May an organization use an application program interface (API) that retrieves data directly from a primary or approved source, even though it is not a web crawler?

Yes. Organizations may use an API to access data from a primary or approved source, and must provide documentation that the API collects information only from primary or approved sources.

Organizations that use an API must still meet the “Appropriate documentation” requirements in CVO 1, Element A, including documentation that the organization's staff reviewed the information.

As noted in an FAQ from February 15, 2023, use of another entity’s software to collect credentialing information is not considered delegation unless the entity also reviews the information on the organization’s behalf.

CVO 2022

6.23.2023 July 2023 PCMH Summary of Updates What changes were made to the PCMH Standards and Guidelines for Version 9?

TopicUpdate Highlights
Front Matter (Audit Section)Added “Evidence of implementation submitted for an audit, including reporting data, must be recent to the time of the audit.”
Front MatterAdded a section addressing conflicts with regulatory requirements. This applies to all Recognition products.
CM 04Added: “Note: After-visit summaries may only be used if they contain plain language and show patient involvement in the plan’s creation.”

Also added, “The care plan is written at a health literacy level accessible to the patient (i.e., does not contain medical jargon, abbreviations/acronyms or billing codes).”

KM 09Removed “pronouns” and “language” in the guidance section as an example of “other aspects of health”.
KM 09Added a clarification about evidence, “Practices are to submit a report that is broken down by numerator/denominator and percentages for each category. For example, Black or African American = 400/1000 (40%); Asian = 300/1000 (30%), etc."
AC 01Added to the guidance: The key to this criterion is patient preference. Some examples of questions asked may include, but are not limited to:
• Our practice is considering extended hours to 7PM. What day of the week would you most prefer?
• Our practice offers same day appointments at 9AM each day. Does this time work for your same day needs? Yes/No with a follow-up question: If not, please identify a time that you prefer.
• If scheduled telehealth visits were offered, would you use them instead of an in-person office visit? (Y/N or Likert Scale). Can follow-up with options.
CM 11New criterion – Person-Driven Outcomes Approach: Monitoring and Follow-Up
QI 01 and 02Clarified that beginning in 2024, standardized measures must be used and reporting through the Measures Reporting Tile in Q-PASS.

PCMH 2017

6.23.2023 July 2023 PCSP Summary of Updates What changes were made to the PCSP Standards and Guidelines for Version 6?

TopicUpdate Highlights
Front Matter (Audit Section)Evidence of implementation submitted for an audit, including reporting data, must be recent to the time of the audit.
Front MatterAdded a section addressing conflicts with regulatory requirements. This applies to all Recognition products.
CM 04Added: “The care plan needs to be written in a health literacy level accessible to the patient (not medical jargon or billing codes).”

Also added – “Note: After-visit summaries may only be used if it contains plain language and shows patient involvement in the creation of the plan.”

KM 06Removed “pronouns” and added “language” in the guidance section as examples that may not be submitted for “other aspects of health”.
KM 09
 		Added clarification on evidence: “Practices are to submit a report that is broken down by numerator/denominator and percentages for each category. For example, Black or African American = 400/1000 (40%); Asian = 300/1000 (30%), etc.”
PM 20New criterion – Person-Driven Outcomes Approach: Monitoring and Follow-Up

PCSP 2019