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.
Save your favorite pages and receive notifications whenever they’re updated.
You will be prompted to log in to your NCQA account.
Save your favorite pages and receive notifications whenever they’re updated.
You will be prompted to log in to your NCQA account.
Share this page with a friend or colleague by Email.
We do not share your information with third parties.
Share this page with a friend or colleague by Email.
We do not share your information with third parties.
Print this page.
Print this page.
No. Medical necessity review is not required for personal care services and other activities of daily living in UM 4–UM 7. However, if these services are covered benefits, any denial decision may be appealed and is included in the scope of appeal file review for UM 9.
No, but health literacy training programs are only a suggested approach for addressing communication needs and reducing barriers for patients and their families to access and understand health and safety information.
If the asthma action plan enables patients to track/monitor their progress and document health information at home using a form or some other method of documentation with helpful instructions for self-management, then it would be acceptable.
No, just having extra appointments based on the season would not meet the intent. The practice may have more same day appointments offered during these high-volume time periods but some same day appointments should be provided daily throughout the year.
For younger children, practices may also identify patients and provide outreach for services for developmental screenings, autism screening, oral health risk assessment, Hematocrit or Hemoglobin screening, iron supplements for children ages 6 to 12 months at risk for anemia, or tuberculin testing for children at higher risk for tuberculosis
For adolescent patients, other preventive care services could also include (but not limited to) patients in need of specific preventive care-related lab tests, alcohol and drug screening, cervical dysplasia screening for sexually active females, sexually transmitted infection prevention counseling for adolescents at higher risk, obesity screening and counseling, HIV screening for adolescents at higher risk or other required screenings (e.g., chlamydia, depression, dyslipidemia at specific ages).
AAP resources:
Recommendations for Preventive Pediatric Health Care (PDF): https://brightfutures.aap.org/materials-and-tools/PerfPrevServ/Pages/default.aspx
Interactive Periodicity Schedule (AAP Pediatric Care Online- Web resource): https://pediatriccare.solutions.aap.org/periodicity-schedule.aspx
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition (Web site and links to associated text/materials): http://brightfutures.aap.org/index.html
Practices need to identify behavioral health-related criteria pertinent to their specific patient population such as a behavioral health diagnosis, substance use, a positive screening result from a standardized behavioral health screen, or psychiatric hospitalizations. If the practice feels that patients with temper tantrums is an identifier for patients in need of care management, the practice can use that defining criteria.
NCQA is not prescriptive regarding which depression screening tool is used as long as it’s a standardized tool. Some depression screening tool examples that would be appropriate for adolescents include but are not limited to PHQ2, PHQ9, PHQ-A, PSC, PSC-Y, RAAPS, or HEADSS.
