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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1.15.2025 Privacy Protections for Data Is access to physical and cloud servers in the scope of the Privacy Protections of Data requirement?

Yes. The intent of LTSS 2, Element B in CM-LTSS (HE 2, Element F in HEA; LTSS 1, Element E in HPA) is that organizations have policies and procedures in place for managing access to and use of race/ethnicity and language data that cover all forms of media, devices and data storage.

This applies to the following Programs and Years:
CM-LTSS 2024|HEA 2024|HP 2025

1.15.2025 NPDB: Acceptable Source for Medicare and Medicaid Exclusions (MBHO) Is the NPDB an acceptable source for Medicare and Medicaid exclusions?

Yes. The NPDB is an acceptable source for both Medicare and Medicaid exclusions.  

For Medicaid, organizations must obtain exclusion information from the state Medicaid agency, in addition to either of the following sources: 

  • NPDB, or 

  • List of Excluded Individuals and Entities maintained by OIG and available over the internet). 

For Medicare, organizations may obtain exclusion information from any of the NCQA acceptable sources. 

This applies to the following Programs and Years:
MBHO 2025

1.15.2025 Sources for Medicare Sanctions (MBHO) Are organizations required to verify Medicare sanctions from all of the following sources?
• AMA Physician Master File.
• FSMB.
• NPDB.
• SAM.gov.

No. The requirement is that organizations verify Medicare sanctions from any of those sources, but there is no requirement to verify sanctions from all of them. 

This applies to the following Programs and Years:
MBHO 2025

1.15.2025 Reviewer Names on Denial and Appeal Notifications (MBHO & UM) Does NCQA require names or signatures of the reviewers on UM denial and appeal notifications?

No. NCQA does not require names or signatures of the reviewers on UM denial and appeal notifications. Please refer to UM 4, Element C and UM 9, Element D for documentation requirements. 

This applies to the following Programs and Years:
MBHO 2025|UM-CR-PN 2025

1.15.2025 Use of documents produced using the Consolidated Clinical Document Architecture (C-CDA) standard Can documentation produced using the C-CDA standard, such as Continuity of Care Documents (CCD), discharge summaries or progress notes, be used as proof-of-service documentation or medical record review?

No. Documents produced using the C-CDA standard are structured summaries or snapshots of information used to facilitate data exchange. They are not eligible as proof of service for HEDIS MY 2024, and should not be used for medical record review abstraction.  

This applies to the following Programs and Years:
HEDIS MY 2024

12.16.2024 NPDB Acceptable Source for Medicare and Medicaid Exclusions Is the NPDB an acceptable source for Medicare and Medicaid exclusions?

Yes. The NPDB is an acceptable source for both Medicare and Medicaid exclusions.

For Medicaid, organizations must obtain exclusion information from the state Medicaid agency, in addition to either of the following sources:

  • NPDB, or
  • List of Excluded Individuals and Entities maintained by OIG and available over the internet).

For Medicare, organizations may obtain exclusion information from any of the NCQA acceptable sources.

This applies to the following Programs and Years:
HP 2025|CRPN 2025

12.16.2024 Reviewer Names on Denial and Appeal Notifications Does NCQA require names or signatures of the reviewers on UM denial and appeal notifications?

No. NCQA does not require names or signatures of the reviewers on UM denial and appeal notifications. Please refer to UM 4, Element C and UM 9, Element D for documentation requirements.

This applies to the following Programs and Years:
HP 2025

12.16.2024 MMP Plans CMS intends to dissolve Medicare-Medicaid Plan (MMP) contracts in 2026. Will that change product line rules for Accreditation?

No. Plans that are responsible for both the Medicare and Medicaid components for dual-eligible members may select Medicare, Medicaid, or both, for Accreditation purposes. 

This applies to the following Programs and Years:
HP 2025

12.16.2024 Sources for Medicare Sanctions Are organizations required to verify Medicare sanctions from all of the following sources?
• AMA Physician Master File.
• FSMB.
• NPDB.
• SAM.gov.

No. The requirement is that organizations verify Medicare sanctions from any of those sources, but there is no requirement to verify sanctions from all of them. 

This applies to the following Programs and Years:
HP 2025|CRPN 2025

12.13.2024 Advance Notice of RAND Table Changes for HEDIS MY 2025 How is NCQA changing the release of RAND numbers for HEDIS reporting beginning in MY 2025?

NCQA will remove the RAND table from the Guidelines for Calculations and Sampling with the release of the HEDIS MY 2025 Technical Update on March 31, 2025. Future releases of the HEDIS Volume 2: Technical Specifications for Health Plans publication will not contain a RAND table.

Beginning MY 2025, NCQA will use an alternative timeline and approach to distribute RAND numbers for HEDIS reporting. This information will be released in the NCQA store for purchasers of HEDIS Volume 2 in the November before production of systematic samples for hybrid reporting (e.g., November 2025, for MY 2025).  

Organizations participating in NCQA’s Measure Certification program will receive separate guidance on how NCQA will accommodate this change for certification of systematic sampling logic.

This applies to the following Programs and Years:
HEDIS MY 2025

11.15.2024 Inconsistency with Member-Reported Services Requirements What are common themes in data containing member-reported services that suggest noncompliance with HEDIS requirements and should not be used?

Common themes include:

  • Clinical accountability for the information.
    An arrangement may exist where a provider, such as a PharmD, interacts with members to collect information on their last colorectal cancer screening or breast cancer screening. It is unclear if a PharmD has the appropriate clinical training to document the complete context of the service or interpret the information being shared. Nor is it evident that a PharmD would be clinically accountable for that aspect of the member’s care (preventive cancer care).

Another arrangement that may exist includes workflows where providers (e.g., NPs, PAs) contact a plan’s membership annually to assess a member’s medical history, including when they received their last cancer screenings. It is unclear if a singular touchpoint by the NP/PA indicates that the provider has clinical accountability for the member’s care. Organizations are not allowed to call members to collect data.

  • Including and maintaining information in the health record.
    A member’s health record should be accessible to the member and the care team responsible for that aspect of their care. Systems that are internal-facing only to a plan do not represent a source of data that contribute to an individual’s ongoing clinical care. Further, an individual’s health record should be available to them to reference or share with a care team in the future.

This applies to the following Programs and Years:
HEDIS MY 2024, 2025

11.15.2024 Implementation Plans for Health Equity Will the implementation plan deadlines be extended for the 2024 Health Equity Accreditation and Health Equity Accreditation Plus products? 

Yes. For Initial Surveys scheduled on or between July 1, 2024, and June 30, 2026, the organization may submit a detailed implementation plan that includes a timeline as evidence for applicable factors.  

 

Implementation plans may be submitted for Initial Surveys for the following requirements until June 30, 2026: 

 

  • HE 2, Element A. 

  • HE 2, Element D. 

  • HE 2, Element E. 

  • HE 2, Element G. 

  • HE Plus 3, Element C. 

  • HE Plus 5, Element B. 

  • HE Plus 5, Element E. 

This applies to the following Programs and Years:
HEA 2024, Plus