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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1.16.2024 3-Dose-Series Prevnar 20 Pneumococcal Vaccine for Childhood Immunization Status (CIS) When will PCV20 pneumococcal vaccine be added to the pneumococcal conjugate value sets?

We anticipate that PCV20 will be added to the CIS value sets in the HEDIS MY 2024 Technical Update, scheduled for release on April 1, 2024.
Although the PCV20 vaccine is not included in the measure for MY 2023, NCQA does not anticipate this will impact performance. The measure denominator only includes children who were at least 18 months old and expected to have already completed the pneumococcal series by June 2023 (the month when ACIP recommended PCV20).

HEDIS 2024

12.15.2023 Collaboration Between Medical Care and Behavioral Health Care Does collaboration between health plan staff clinicians meet the intent of the collaboration requirement in QI 4, Elements A and B?

Typically, no as health plan staff are not practicing practitioners within the health plan's network. The intent of collaboration requirements are for organizations to demonstrate collaboration between their behavioral healthcare delivery system (network practitioners) and medical care delivery system (network practitioners). 

Note: Demonstrating collaboration with an MBHO is acceptable for the collaboration with “behavioral healthcare practitioners” component of the requirement.

HP 2023

12.15.2023 Updated CR Accreditation Eligibility and Reportable Events The 2024 CR Accreditation standards allow organizations that delegate more than 50% of primary source verifications to be eligible for Credentialing Accreditation, as long as all delegates have NCQA Credentialing Accreditation or NCQA Credentialing/CVO Certification. What happens if a delegate loses Accreditation/Certification status after the organization’s survey?

If an organization delegates more than 50% of primary source verifications and one or more of its delegates loses Accreditation/Certification status, NCQA considers this a Reportable Event. The organization must notify NCQA (through My.NCQA.org) within 30 calendar days.

UM-CR-PN 2024

11.22.2023 CM 04 For CM 04, what does “the care plan is written at a health literacy level accessible to the patient” mean?

This means that the information is not all medical jargon. So instead of the care plan stating, “1 PO BID”, the practice may say “take one by mouth two times a day.” Instead of hardcoded complex diagnosis names and codes, write the diagnosis in common language. For example, instead of only providing the diagnosis of “dyspnea,” use “shortness of breath.”  

The intent is to ensure that the patient understands his/her condition(s), goals, and plans to follow to improve their health.  

PCMH 2017

11.22.2023 CM 04 For CM 04, what does it mean that the care plan must show patient involvement in its creation?

The document should not simply be a hardcoded paper that auto-populates structured fields from the EHR into the document. It should contain language showing that the patient provided input and understands the plan. NCQA is not prescriptive on specific verbiage that must be in the care plan. 

The intent of CM 04 is to give the patient ownership and the power to improve their health outcomes. Engaging the patient in the development of their care plan can result in greater success and adherence to treatment goals.  

PCMH 2017

11.16.2023 Data source for “Asked But No Answer” reporting category To what data source should organizations attribute the “Asked But No Answer” race and ethnicity reporting category?

The “Asked But No Answer” reporting category reflects members who were asked for race or ethnicity data, but who declined to provide a response. This reporting category must be attributed to a direct data source because the members self-reported by declining to answer.

HEDIS 2023

11.16.2023 MY 2023 Race and Ethnicity Stratification (RES) HEDIS Compliance Audit Requirements Are there new audit requirements for race and ethnicity stratification reporting for MY 2023?

No. Volume 5: HEDIS Compliance Audit MY 2023 does not include new requirements for reporting race and ethnicity. Consistent with MY 2022, these data are addressed in the HEDIS Roadmap. Auditors must confirm that organizations provide a complete Roadmap response, and review all attachments describing data flow, layout and transformation. Roadmap Section 6, Question 6.3J requires organizations to describe the sources they use, their processes for disaggregating race and ethnicity fields, their data source reconciliation and prioritization processes and the percentage of members with available data.  

NCQA introduced a direct data threshold of ≥20% for Race/Ethnicity Diversity of Membership (RDM) in the 2024 Health Plan Ratings scoring methodology. Please note that this is independent from the race and ethnicity stratifications, and should not impact audit designations. There are no bias thresholds for the race and ethnicity stratifications in Volume 5.

HEDIS 2023

11.16.2023 Definition of “Unknown” reporting category for race and ethnicity values When can organizations report race and ethnicity as an “Unknown” value?

“Unknown” race and ethnicity values indicate missing data. Two criteria must be met to report “Unknown”: 

1. There is no recorded value, and  

2. The organization did not receive a declined response from the member. 

Starting in MY 2023, all “Unknown” values must be attributed to an unknown data source. This is a change from MY 2022, when “Unknown” values were attributed to an indirect data source.   

HEDIS 2023

11.16.2023 Sources with populated race or ethnicity values of “Unknown” or “Two or More Races” How should organizations handle data sources with values of “Unknown” or “Two or More Races”?”

NCQA strongly discourages using “Unknown” and “Two or More Races” response categories when collecting race and ethnicity data. When possible, organizations should instead use and encourage alternatives such as: 

  • “Other” or “None of the above” response options for members who are unsure of their race or ethnicity. 

  • The ability to select multiple race values for members with two or more races. 

If “Unknown” or “Two or More Races” are populated values in sources where health plans cannot improve response terms/options, they can be mapped to the “Some Other Race” reporting category. 

HEDIS 2023

11.15.2023 Codes for Race and Ethnicity Stratification (RES) Are LOINC codes used to identify race and ethnicity?

No. Codes to identify race and ethnicity resemble some LOINC codes (i.e., the same format), but are derived from a code system developed by the U.S. Centers for Disease Control and Prevention (CDC).
The code is the same across terminologies in multiple instances. NCQA recommends that organizations establish data quality controls to avoid inadvertent data reporting errors. For example, “2106-3” could result in errors if used incorrectly:

  • 2106-3 = “White” (CDC Race and Ethnicity).
  • 2106-3 = “Choriogonadotropin (pregnancy test) [Presence] in Urine” (LOINC).

HEDIS 2024

11.15.2023 HEDIS Roadmap Documentation Requirements for Aggregators What HEDIS Compliance Audit Roadmap documentation is required by health plans for data sources provided from an aggregator (e.g., health information exchange)?

It depends:

  • For data streams provided by aggregators with a current approved validation status in the NCQA Data Aggregator Validation program, only Roadmap Section 5 from the plan is required. 
  • For all other data streams provided by aggregators that are not validated in the DAV program, a Roadmap Section 5 from the plan and Section 5a from the aggregator are required.

NCQA maintains an online directory of entities with validated data streams.

HEDIS 2024

11.15.2023 Members Recommended for Routine Cervical Cancer Screening The Cervical Cancer Screening (CCS and CCS-E) measures include the following criteria to identify members recommended for routine cervical cancer screening:
• Administrative Gender of Female (AdministrativeGender code F) any time in the member’s history.
• Sex Assigned at Birth (LOINC code 76689-9) of Female (LOINC code LA3-6) any time in the member’s history.
• Sex Parameter for Clinical Use of Female (SexParameterForClinicalUse code Female-typical) during the measurement year.
What data sources can be used to identify these members?

When reporting CCS-E, all three methods may be used, using any data source. When reporting CCS, use only administrative data (Administrative Gender of Female [AdministrativeGender code F] any time in the member’s history) to determine members recommended for routine cervical cancer screening.
Where supplemental data may be used for CCS remains the same for MY 2024. Supplemental data may not be used for denominator criteria, except in required exclusions.

HEDIS 2024