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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6.15.2023 Use of a Delegate's Self-Service Portal for Delegation Reporting Is it acceptable for organizations to pull reports from a delegate’s system for the delegation agreement reporting requirement?

Yes, if the delegation agreement addresses the required information in the Explanation. The delegation agreement must specify:

  • How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
  • What information is reported by the delegate in the delegate's system about the delegated activities.
  • How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).

WHP 2019

6.15.2023 Use of Delegate's Self-Service Portal for Delegation Reporting Is it acceptable for organizations to pull reports from a delegate’s system for the delegation agreement reporting requirement?

Yes, if the delegation agreement addresses the required information in the Explanation (e.g., CR 8, Element A, factor 3 for credentialing). The delegation agreement must specify:

  • How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
  • What information is reported by the delegate in the delegate's system about the delegated activities.
  • How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).

UM-CR-PN 2023

5.15.2023 Colorectal Cancer Screening (COL-E) Should the Colorectal Cancer Screening-E (COL-E) age stratification be updated?

Yes. Replace the reference to “46-49” with “46-50,” and replace the reference to “50-75” with “51-75” in the age stratification and in Table COL-E-A-4: Data Elements for Colorectal Cancer Screening.

Exchange 2023

5.15.2023 Social Need Screening and Intervention (SNS-E) Should the SNS-E measure include exclusion criteria for Medicare members?

No. There are no Medicare member exclusions. Remove the second bullet from Exclusion 1, which reads:

  • Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
    • Enrolled in an Institutional SNP (I-SNP) any time during the measurement period.
    • Living long-term in an institution any time during the measurement period, as identified by the LTI flag in the Monthly Membership Detail Data File. Use the run date of the file to determine if a member had an LTI flag during the measurement period.

Exchange 2023

5.15.2023 MBHO: Applicable Standards for Mail Service Organizations Considered Delegates What standards are considered a delegation relationship if an organization uses a mail service organization to meet the distribution requirements?

NCQA considers the following standards to be a delegation relationship if an organization uses a mail service organization to meet the distribution requirements:

  • CC 3, Element A: Notification of Termination
  • CC 3, Element B: Continued Access to Practitioners
  • UM 5, Element A: Timeliness of UM Decisions
  • UM 7, Elements B, C: Denial Notices
  • UM 9, Elements B, D: Appropriate Handling of Appeals

MBHO 2023

5.15.2023 Definition of Annual Does NCQA’s definition of “annual” allow for a 2-month grace period?

As noted in the Glossary appendix, NCQA’s long-standing definition of “annual” is 12 months plus a 2-month grace period (12–14 months). “Grace period” refers to allowing organizations to complete an activity after it is due and not before it is due.

CM-LTSS 2023

5.15.2023 Applicable Standards for Mail Service Organizations Considered Delegates What standards are considered a delegation relationship if an organization uses a mail service organization to meet the distribution requirements?

NCQA considers the following standards to be a delegation relationship if an organization uses a mail service organization to meet the distribution requirements:

  • NET 4, Element A: Notification of Termination
  • NET 4, Element B: Continued Access to Practitioners
  • UM 5, Elements A, B, C: Timeliness of UM Decisions
  • UM 7, Elements B, C, E, F, H, I: Denial Notices
  • UM 9, Elements B, D: Appropriate Handling of Appeals
  • UM 11, Element B: Pharmaceutical Restrictions/Preferences
  • UM 11, Element C: Pharmaceutical Patient Safety Issues

UM-CR-PN 2023

4.24.2023 Health Plan Ratings Information Confirmation Why do I have to confirm this information if our plan is not Accredited, or we will say “No” to Public Reporting?

We need you to confirm your plan details (e.g., Accreditation status, State Coverage, Family Association, Organization ID, Submission ID) because this impacts how you will be listed publicly when we release HPR on or around September 15, regardless of your Accreditation status or Public Reporting decision.

HPR

4.24.2023 Electronic Clinical Data Distinction (ECDS) in Health Plan Ratings/Report Cards Where can I find more information regarding the Electronic Clinical Data distinction?

4.24.2023 Accreditation Status in Health Plan Ratings How is my Accreditation status used in HPR and how will it be displayed?

We use your Accreditation status as of June 30 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 Plan) as of June 30, 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 (Interim) – CAP; Yes (Provisional) – CAP; Yes – Under Review by NCQA; Yes (Interim) – Under Review by NCQA; Yes (Provisional) – Under Review by NCQA; No; No (Scheduled); No (In Process).

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.

HPR

4.24.2023 Health Plan Ratings Overview How do the Ratings work, in brief?

NCQA’s HPR overall rating is the weighted average of a plan's HEDIS, CAHPS and HOS (Medicare only) measure ratings, plus Accreditation bonus points (if the plan is Accredited by NCQA), rounded to the nearest half point displayed as Stars. Dozens of measures are calculated on a 0–5 scale in half-points (5 is highest) by comparing the plan submitted rate to The National All Lines of Business 10th, 33.33rd, 66.67th and 90th measure benchmarks.
 

 

HPR

4.24.2023 Plan Confirmation CAHPS Survey As a Medicaid plan, I can choose to be scored on Adult CAHPS, on Child CAHPS or on the General Population of Child CCC CAHPS. Why can’t I change my selection in plan confirmation?

Your CAHPS Component selection was made in the HOQ. It is final and cannot be modified.

HPR