FAQ Directory

No. Organizations should not provide any documentation for HE 6, Element B, factor 3. The entire factor 3 requirement is NA for all surveys through June 30, 2026

This applies to the following Programs and Years:

Yes. When an organization conducts its UM Information Integrity audit, the audit universe includes data from the most recent 12 months from the timing of the audit. So, although the audit occurs within the look-back period, data reviewed may  include decision notification files from outside the formal look-back window, depending on timing. 

This applies to the following Programs and Years:

Unless a regular operational employee of the organization, a consultant is not to assume responsibility for generating or demonstrating the evidence for Recognition. While external consultants are welcome to be part of the virtual reviews or audit, these calls are led by the appropriate practice team members.  NCQA reserves the right to obtain contact information of consultants working with the practice as well as verify the identity of individuals present during the virtual review or audit.

This applies to the following Programs and Years:

Every qualifying clinician at a practice site is required to be listed in Q-PASS. Clinicians who meet the following three criteria must be listed for each Recognized PCMH site they practice at:

1. MDs, DOs, PAs and APRNs (including nurse practitioners and clinical nurse specialists) who practice internal medicine, family medicine or pediatrics.
2. The clinician can be selected by patients as their primary care clinician. 
3. The clinician has their own or shares a patient panel.

This applies to the following Programs and Years:

Any structural or operational change must be reported to NCQA. Organizations must contact their NCQA Representative for further instructions within 30 days of the change.

This applies to the following Programs and Years:

If a reviewer is external to the organization, the title/role must reflect it (e.g., “External Reviewer,” “External Independent Reviewer”). 

This applies to the following Programs and Years:

Yes. Applicable clinical staff must be licensed and verified in all states where they provide care to members. 

A licensure compact arrangement between states is acceptable if the clinician’s licensure was primary source verified in the clinician’s home state. NCQA reviews the compact agreement for evidence that the state (or states) accepts the home state’s license in lieu of state licensure. 

This applies to the following Programs and Years:

It is up to the organization to ensure that multiple mammograph episodes are the same event if they occur on the same date of service. HEDIS measure certification assumes events on the same day are different mammograms. If evidence shows the mammography episodes are the same, count only one. Organizations should develop their own methods and apply them consistently when reporting.

This applies to the following Programs and Years:

Yes. One follow-up event may meet criteria for multiple BIRADS assessments. Each BIRADS assessment counts as separate denominator events, and requires the appropriate follow-up to count toward the numerator. However, one breast biopsy may meet criteria for multiple high-risk BIRADS assessments, and one mammogram or ultrasound may meet criteria for multiple inconclusive BIRADS assessments.

This applies to the following Programs and Years:

No. Each mammogram requires a unique BIRADS assessment (e.g., two mammograms need two separate BIRADS to meet numerator criteria). A single documented BIRADS assessment dated on or within 14 days (15 days total) of multiple mammography episodes does not meet criteria for multiple denominator events.

DBM-E sample and test decks have been updated and re-posted. If you already received a status of “pass” for a DBM-E test deck, the status has been re-set and you must run the updated deck to certify. The deadline to certify the measure will be extended to July 31 so organizations can accommodate this update.

This applies to the following Programs and Years:

Cadence Thresholds Added:
Cadence thresholds are applied to 45 criteria to ensure continuous improvement and to avoid stagnation in workflows (i.e. “at least annually").
 

This applies to the following Programs and Years:

Best Practices from NCQA’s Virtual Primary Care Program to PCMH:
The following elective criteria were written during the creation process of the new Virtual Care program, but found to be best practice for all primary care settings. For this reason, nine new elective criteria are added to the PCMH program.
 

This applies to the following Programs and Years: