FAQ Directory

This applies to the following Programs and Years:

Yes. As described in Numerator 5—Immunization Status: Hepatitis B, use POS code 81 to exclude laboratory claims when identifying members with a history of hepatitis B illness. POS code 81 was mistakenly omitted from the Direct Reference Code tab of the VSD. Because the information needed for reporting is in the measure specification, NCQA does not intend to reissue the VSD.

This applies to the following Programs and Years:

Yes. This data element is a calculated field in IDSS, and it should be shaded gray. We will correct this in the release of the MY 2026 Volume 2 Technical Specifications.

This applies to the following Programs and Years:

Yes. NCQA has worked with CAQH to add a notice to its practitioner- and customer-facing provider credentialing applications, recognizing that discriminatory uses of race, ethnicity and language data are prohibited. CAQH is going live with the application update on 7/1/25.

The use of the CAQH application will be acceptable to meet CR 3, Element C, factor 6: Race, ethnicity and language in the 2025 Health Plan Accreditation standards and guidelines (and applicable products).

This applies to:
HPA: CR 3, Element A, factor 6
CRPN: CRA 3, Element A, factor 6, CRC 10, Elements A, factor 6
MBHO: CR 3, Element A, factor 6

This applies to the following Programs and Years:

The requirement is for the application to have separate fields to enter responses for each of these three data points (race, ethnicity, and language). However, it would be acceptable to group these into one question if the application prompts the user to provide separate responses for race, ethnicity and language. 

Responses provided through the CAQH online portal for credentialing data application are acceptable. Although the online portal supporting the credentialing application groups the responses for race and ethnicity into one field, the practitioner is prompted to provide separate responses within the system. When a practitioner chooses his/her race, the practitioner is then prompted to provide his/her ethnicity information. Language is captured via a separate field.  

This applies to:
HPA: CR 3, Element A, factor 6
CRPN: CRA 3, Element A, factor 6, CRC 10, Elements A, factor 6
MBHO: CR 3, Element A, factor 6

Note:  A related question was posted on 3/17/2025: “Credentialing Application: Race, Ethnicity and Language (REL).” This FAQ is an update to that post. 

This applies to the following Programs and Years:

No. The codes are for “amitriptyline hydrochloride 25 MG/chlordiazepoxide 10 MG Oral Tablet.” They belong only in the Chlordiazepoxide 10 MG Medications List. NCQA re-released the MY 2025 Medication List directory on May 15, 2025, to incorporate this update. NCQA’s Measure Certification program confirmed that certification organizations deleted the codes from the Chlordiazepoxide 25 MG Medications List. No changes to the current process are necessary.

This applies to the following Programs and Years:

Yes. If the HPV or Pap test sample source is vaginal, and can be billed to an appropriate code in the value sets, it may be used to meet criteria.

This applies to the following Programs and Years:

Yes, if the software uses the organization’s clinical criteria, policies and procedures and benefit package information, and the organization maintains control over the software implementation. Organizations may not use the software to make any denial decisions; those must be made by an appropriate clinical professional. Appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.

NCQA considers the use of external software to make approval decisions to be a vendor relationship for applicable requirements (e.g., UM 4, Element F). Refer to Appendix 3: Delegation and Automatic Credit Guidelines for additional information.

This applies to the following Programs and Years:

If an organization does not have evidence that, during the look-back period, it assisted members transition to care when their benefits were exhausted (QI 3, Element E), NCQA reviews the organization’s policies and procedures in place throughout the look-back period.

In addition to the policies and procedures, the organization must provide documentation (e.g., attestation) indicating that there were no such instances during the look-back period. 

This applies to the following Programs and Years:

In the 2024 Health Plan Ratings, Follow-Up After High Intensity Care for Substance Use Disorder (FUI) was removed from the final ratings for the Medicare product line due to insufficient data in MY 2023 HEDIS submissions.

If a measure is not required in the 2024 Health Plan Ratings, it is not required in QI 3. Thus, because FUI was not included in the most recent scoresheet for the Medicare product line, it   is not included in the average calculation in Element B and will not be considered (may not be chosen as a measure to act on) in Element C.

This applies to the following Programs and Years:

Yes. The following changes apply to SNP 2, Assessing and Coordinating Care.

NCQA added a new Element F, Contracts with Long-Term Care Institutions for I-SNP Members, that requires organizations to confirm that contracts with long-term care institutions for its I-SNP members, allow I-SNP clinical and care coordination staff access to I-SNP members who are institutionalized.

NCQA will review materials submitted by the organization that demonstrates that the organization’s contracts for I-SNP members allow I-SNP clinical and care coordination staff access to I-SNP Members who are institutionalized.

An institutionalized individual is defined in CFR § 422.2 as a special needs individual, and for the open enrollment period for institutionalized individuals at § 422.62(a)(4), an MA eligible individual who continuously resides or is expected to continuously reside for 90 days or longer in one of the following long-term care facility settings:

(1) Skilled nursing facility (SNF) as defined in section 1819 of the Act (Medicare).
(2) Nursing facility (NF) as defined in section 1919 of the Act (Medicaid).
(3) Intermediate care facility for individuals with intellectual and developmental disabilities as defined in section 1905(d) of the Act.
(4) Psychiatric hospital or unit as defined in section 1861(f) of the Act.
(5) Rehabilitation hospital or unit as defined in section 1886(d)(1)(B) of the Act.
(6) Long-term care hospital as defined in section 1886(d)(1)(B) of the Act.
(7) Hospital which has an agreement under section 1883 of the Act (a swing-bed hospital).
(8) Subject to CMS approval, a facility that is not listed in paragraphs (1) through (7) of this definition but meets both of the following:

(i) Furnishes similar long-term, healthcare services that are covered under Medicare Part A, Medicare Part B, or Medicaid; and
(ii) Whose residents have similar needs and healthcare status as residents of one or more facilities listed in paragraphs (1) through (7) of this definition.

This new element is NA for C-SNP and D-SNP members. 

This applies to the following Programs and Years:

No. For standards year 2025 only, NCQA will allow all organizations, regardless of their audit schedule, to submit a detailed implementation plan in lieu of conducting the delegation oversight information integrity audit.    

The implementation plan for each applicable delegate must include:

• The delegate’s name.
• The entity conducting the audit (organization or delegate).
  • If the delegate conducts the audit, the implementation plan must include the organization’s plan for review and evaluation of audit findings.
• The title of staff who conduct the audit.
• The audit methodology.
• The audit due date.

Organizations must submit either an information integrity audit report or an audit implementation plan (for selected delegates) at the time of survey submission for the following products:

• HP: UM 13, Element C, factors 5-7; CR 9, Element C, factors 5-7.
• CRPN: CR 3, Element C, factors 5-7.
• UMCRPN: UM 13, Element C, factors 5-7.
• MBHO: UM 12, Element C, factors 5-7; CR 9, Element C, factors 5-7. 

Organization-level information integrity audits must be conducted, and an implementation plan is not acceptable for the following requirements: 

• HP: UM 12, Element D; UM 12, Element F, CR 8, Element C.  
• CRPN: CR 2, Element C.
• UMCRPN: UM 12, Element D; UM 12, Element F.
• MBHO: UM 11, Element D; UM 11, Element F; CR 8, Element C.

Note: A related question was posted on 1/15/2025: “Do organizations need to conduct a delegation audit(s) on the 2025 Information Integrity standards within 12 months prior to survey submission date?” This FAQ replaces that post.

This applies to the following Programs and Years: