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.

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10.15.2015 Off-Marketplace in Accreditation If Off-Marketplace plans are not required by CMS to be in QRS, are they still required to include their membership in commercial product line when submitting for health plan accreditation?

Yes, Off-Market plans are required to be in the commercial product line when submitting for health plan accreditation.

This applies to the following Programs and Years:

10.15.2015 Oral notification of expedited appeal decisions UM 5 allows organizations to provide initial oral notification for urgent requests, with written notification within three calendar days. Does this also apply to expedited appeal decisions in UM 9, Element B?

Yes. Organizations may provide oral notification, followed by written/electronic notification within three calendar days.

This applies to the following Programs and Years:
UM-CR 2013

10.15.2015 P4P Overview In the draft version of the MY 2015 Value Based P4P Manual released on 9/1/2015, page 6 indicates that the PO deadline for supplemental data collection is February 15, 2016, and the supplemental data validation deadline is March 15, 2016. Under the Supplemental Data Validation Deadline Activity, the last sentence states “Primary source verification (PSV) for member-reported and nonstandard supplemental data must not occur prior to March 2 unless the organization finished all supplemental data processes, collection and entry.”
Should the last sentence be updated to say February 15 instead of March 2?

Yes, you are correct; the date in the last sentence under Supplemental Data Validation Deadline should state:

“Auditor finalizes approval of all supplemental data. Primary source verification (PSV) for member-reported and nonstandard supplemental data must not occur prior to February 15 unless the organization finished all supplemental data processes, collection and entry.”

We will update this for the final version of the MY 2015 Value Based P4P Manual, released on December 1, 2015.

This applies to the following Programs and Years:
IHA P4P

10.15.2015 Complaints and Appeals Analysis for Marketplace product line May an organization submit one report for all its product lines, including its Marketplace product line?

The organization may submit one analysis report for all its product lines, including Marketplace, but the analysis for the Marketplace line must be separate in order to receive credit for QI 12, Element C.

This applies to the following Programs and Years:

10.15.2015 Delegation revocation and documentation If an organization revokes delegation, may the organization receive “NA” scoring if the delegate does not provide the necessary documentation?

No. The organization is responsible for meeting NCQA requirements even if it terminates the delegation agreement. 

This applies to the following Programs and Years:

9.30.2015 QRS and Off-Market Commercial HEDIS Submission Should Off-Marketplace plans include their membership in QRS and in Marketplace accreditation?

No. Off-Marketplace plans should include its membership in its commercial HEDIS submission and in its commercial product line when submitting for health plan accreditation.

This applies to the following Programs and Years:
Exchange 2016

9.15.2015 Documentation requirements for file review when delegating to a certified CVO What documentation must an NCQA-Certified CVO provide to an organization for an accreditation survey file review?

The organization and the CVO determine the documentation methods for reporting information. Acceptable methods include a checklist, the actual documents and access to electronic credentialing files. When an organization delegates to a certified CVO, NCQA reviews the organization’s credentialing files to assess timeliness and ascertain whether the credentialing decision was made within the specified time limits (i.e., 180 calendar days from verification).

This applies to the following Programs and Years:
CVO 2013

9.15.2015 Acceptable Documents for Policies and Procedures Many scopes of review in the standards require policies and procedures. How does NCQA define “policies and procedures” and what are acceptable documents?

Policies and procedures are official documents that describe business rules and a course of actions, and the methods for carrying out the actions. Simply put, policies and procedures specify how an organization performs the requirement under review—the organization’s “documented process.”
Usually, NCQA expects the organization to present only the components of the policies and procedures that demonstrate it meets the requirement. Depending on the element, this may include, but is not limited to, a program description, operating guidelines or process flowchart. 

 

This applies to the following Programs and Years:
HIP 2014|WHP Cert|2016 DM|2014 UM-CR

9.15.2015 Specificity of the Vendor Acknowledgment If an organization contracts with a vendor to meet NCQA requirements (e.g., MEM 1, MEM 2), how specific does the written vendor acknowledgment have to be?

If the vendor performs all functions (i.e., MEM 1: Health Appraisals), the written acknowledgment must state that the vendor performs all functions. If the vendor does not perform all functions, the acknowledgment must explicitly state the responsibilities of the vendor and those retained by the organization.

This applies to the following Programs and Years:

8.15.2015 Automatic credit for file review elements delegated to an NCQA-Accredited/Certified entity How is an organization scored for file review elements if the delegation agreement is signed just before survey submission?

The organization receives automatic credit for files selected from the NCQA Accredited/Certified delegate if the agreement is signed before survey submission and if all automatic credit requirements are met, as described in the delegation appendix, unless delegation is with an NCQA-Certified CVO. In that case, the organization receives automatic credit for verification, but files are reviewed for timeliness.

This applies to the following Programs and Years:

8.15.2015 Printed directory requirement in QI 12 Are printed directories required for QI 12, Elements A and B?

No. Printed directories are not required for Elements A and B; however, if there is a printed directory, it must reference the quality information required by the elements.

This applies to the following Programs and Years:

8.14.2015 General Guidelines Are members with a hospice benefit excluded from Medicare HEDIS reporting?

Yes. For Medicare reporting, exclude members who elect to use the hospice benefit (i.e., use hospice service) any time during the measurement year. These members must be removed prior to determining the measure’s eligible population and drawing the sample for hybrid measures.

This applies to the following Programs and Years:
HEDIS 2016