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.

Filter Results
  • Save

    Save your favorite pages and receive notifications whenever they’re updated.

    You will be prompted to log in to your NCQA account.

  • Email

    Share this page with a friend or colleague by Email.

    We do not share your information with third parties.

  • Print

    Print this page.

11.15.2023 CVO: Using SAM.gov for Medicare/Medicaid Sanctions Is SAM.gov an acceptable source for verifying Medicare and Medicaid sanctions?

Yes. Organizations may use SAM.gov to verify Medicare and Medicaid sanctions for CVO 11, Element A and CVO 14, Element C.

CVO 2022

11.15.2023 Using SAM.gov for Medicare/Medicaid Sanctions Is SAM.gov an acceptable source for verifying Medicare and Medicaid sanctions?

Yes. Organizations may use SAM.gov to verify Medicare and Medicaid sanctions for CR 3, Element B, factor 2 and CR 5, Element A, factor 1.

HP 2023

11.15.2023 Notice of Medicare Non-Coverage (NOMNC) Denials For the UM file review universe, should plans include concurrent denials for Medicare members that involve issuance of a Notice of Medicare Non-Coverage (NOMNC) document?

No. Notice of Medicare Non-Coverage (NOMNC) denial files are out of NCQA’s scope of review and should be excluded from the UM file universe.

HP 2023

10.16.2023 Race and Ethnicity Stratification for Childhood Immunization Status (CIS) and Cervical Cancer Screening (CCS) Race and ethnicity stratification criteria are listed for CIS-E but not for CIS, and for CCS-E but not for CCS. Is this intentional?

Yes. Race and ethnicity stratification is not required for traditional reporting of CIS and CCS. The race and ethnicity stratifications are reported when using the Electronic Clinical Data Systems reporting standard for CIS-E and CCS-E.

HEDIS 2024

10.16.2023 Explanation of Benefit (EOB) The digital measure packages for MY 2024 include “Explanation of Benefit” (EOB) criteria. What does that mean?

Although HEDIS digital measure logic references “Explanation of Benefit (EOB),” this is not referenced as a data source in HEDIS Volume 2. In FHIR, the EOB resource represents claims that have been adjudicated, and includes data elements from both Claim and ClaimResponse. The digital logic was written to include the Claim/ClaimResponse resource for claims that are still processing; the ExplanationOfBenefit resource is for claims that are adjudicated.

HEDIS 2024

10.16.2023 Palliative Care Timeframe for Risk of Continued Opioid Use (COU) The time frame for palliative care (bullets 2 and 3 under “Required exclusions”) in the COU measure states to identify palliative care during the measurement period. Is this correct?

No. The correct time frame for identifying palliative care is “at any time during the 365 days prior to the IPSD through 61 days after the IPSD.” This correction will be in the MY 2024 Technical Update.

HEDIS 2024

10.16.2023 UM 13, Element C Exceptions Is the Exceptions section language in UM 13, Element C going to be updated for mail service organizations?

Yes. The following updates to the Exceptions section language are effective immediately and will be included in a Policy Update in November 2023.
This element is NA if:

  • The organization does not delegate UM activities.
  • Delegation arrangements have been in effect for less than 12 months.

Factor 1 is NA for mail service delegates.
Factors 2–6 are NA for Interim Surveys.
Factors 3 and 4 are NA if a mail service delegate distributes information for an element with an annual frequency. The delegation agreement in Element A must outline the frequency for reviewing the delegate’s reports (i.e., annual or semiannual) (UM 13, Element A, factor 4).
Factors 5 and 6 are NA if the delegate only provides cloud-based UM data storage functions and does not provide services that create, modify or use UM data.
Factors 5 and 6 are NA for mail service delegates that:

  • Provide print mail service only. 
  • Do not have access to the organization’s UM system. 
  • Do not have a UM system of their own.
  • Do not modify or store the UM data sent by the organization. 
  • Return UM data provided by the organization.

All bullets must be addressed in a delegation agreement for factors 5 and 6 to be NA.
Factor 6 is NA if the organization did not identify any date modifications or if all identified date modifications met the delegation agreement or the delegate’s policies and procedures.

Note: The strikethrough text indicates changes to the Exceptions section.

HP 2024

10.16.2023 External organizations providing print services only Does NCQA consider it delegation if an organization contracts with an external organization that provides print services only and does not provide mail services?

No. An organization that only provides print services is not considered a delegate or a vendor, and is outside the scope of NCQA requirements.

HP 2023

10.16.2023 UM 13, Element C, factor 2 for mail service delegates Can organizations submit a mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit for UM 13, Element C, factor 2?

Yes. Organizations may submit the mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit. This is not required to be specified in the delegation agreement.

HP 2023

10.16.2023 UM 12, Element C, factor 2 for mail service delegates Can organizations submit a mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit for UM 12, Element C, factor 2?

Yes. Organizations may submit the mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit. This is not required to be specified in the delegation agreement.

MBHO 2023

10.16.2023 Updated: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?

Yes. Using UM 13: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 13, Element A: Delegation Agreement

  • Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution (e.g., UM 11, Element B (annual updates for pharmaceutical restrictions/preferences).
    • Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance, if applicable.
    • Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
  • Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.

UM 13, Element C: Review of the UM Program:

  • Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates.
  • Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
    • Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).

Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit.  This must be specified in the delegation agreement.

Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.

UM-CR-PN 2023

10.16.2023 Updated: MBHO: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?

Yes. Using UM 12: Delegation of UM as an example, the following describes factors that would be considered NA:

UM 12, Element A: Delegation Agreement

  • Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution
    • Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance.
    • Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
  • Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.

UM 12, Element C: Review of the UM Program

  • Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates
  • Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
    • Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).

Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit. This must be specified in the delegation agreement.

Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.

MBHO 2023