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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Yes. The training requirement is new and was not included in the systems controls requirement. The organization must update its delegation agreement to include delegation of UM and CR information integrity training.
The organization may add an addendum to include delegation of the new training requirement. The addendum must be mutually agreed on by the organization and the delegate.
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:
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:
Organization-level information integrity audits must be conducted, and an implementation plan is not acceptable for the following requirements:
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.
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.
Applications processed before July 1, 2025, will not be held to the factor 6 requirement and will be scored NA.
Applications processed on or after July 1, 2025, will be scored on the factor 6 requirement, but will not be held against the 6-month look-back period until surveys on or after January 1, 2026.
Note: CAQH is updating its credentialing application to include fields for race, ethnicity and language, and a statement regarding anti-discrimination. Updates are scheduled to go live on July 1, 2025.
This applies to:
HPA: CR 3, Element C, factor 6.
CRPN: CRA 3, Element A, factor 6; CRC 10, Element A, factor 6; CRC 11, Element A, factor 6.
MBHO: CR 3, Element C, factor 6.
The changes made to the CCS/CCS-E continuous enrollment criteria for QRS MY 2024 was made in error. Use the following continuous enrollment criteria for MY 2024, which align with previous measurement years:
CCS:
Continuous enrollment: The measurement year.
CCS-E:
The member was enrolled with a medical benefit throughout the participation period.
NCQA certified organizations were tested using the accurate continuous enrollment criteria.
Non-file Review Annual Evaluation
If a survey submission date is on or after July 1, 2025, the organization is assessed against the 2025 Standards and Guidelines, and is expected to hold delegate(s) to 2025 requirements.
File Review Annual Audit
If a credentialing file audit (CR 9, Element C, factor 2 in HPA/MBHO; CR 3, Element C, factor 2 in CRPN) is scheduled to occur before July 1, 2025, the organization should continue the routine scheduled annual delegation audits for credentialing and recredentialing files, and audit the files against the 2024 credentialing verification time limits.
If a credentialing file audit is scheduled to occur on or after July 1, 2025, credentialing files processed by the organization’s delegate(s) before July 1, 2025, are assessed against 2024 verification time limits; files processed by the organization’s delegate(s) on or after July 1, 2025, are assessed against 2025 verification time limits.
Yes. During the audit in CR 8, Element C in HPA/MBHO (CR 2, Element C in CRPN), organizations must review all credentialing information in Element A associated with the selected practitioners’ files. This includes all credentialing verification information, credentialing committee minutes and ongoing monitoring reports.
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.
For Health Plan, MBHO and Credentialing Accreditation, “processed” refers to the credentialing decision date.
For Credentialing Certification, “processed” refers to the date when credentialing verifications are reported to the client.
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.
