FAQ Directory

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:

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:

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:

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:

This applies to the following Programs and Years:

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:

This applies to the following Programs and Years:

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:

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:

This applies to the following Programs and Years:

No. Verification of sanctions and exclusions are not product line–specific requirements. For each practitioner in the scope of credentialing, the organization must verify Medicare and Medicaid sanctions regardless of the product line for which practitioners are contracted.

This applies to the following Programs and Years:

HEDIS Volume 2 provides guidance in several places:

• Member-reported services and biometric values general guideline.
  This general guideline states that member-reported services may be used only if collected by a primary care practitioner or specialist (if the specialist is providing a primary care service related to the condition being assessed, in the course of taking a member’s history), and if the information is included in the member’s health record.
• Supplemental data general guideline.
  Information on services reported by members often reside in non-standard supplemental sources. The supplemental data general guideline states that there must be evidence of provider accountability for the information documented. The guideline also states that documentation of member-reported services must be complete (e.g., date, place of service, procedure, prescription, test result or finding, practitioner type).
• Electronic Clinical Data Systems general guidelines.
  Organizations may develop workflows that result in documentation of member-reported services. A common example is documentation in systems identified as case management. The ECDS general guideline states that case management systems are shared, meaning that there is bidirectional access to the data. These data would be accessible to members and to members’ care teams for care coordination and planning.

This applies to the following Programs and Years: