FAQ Directory: Patient-Centered Medical Home (PCMH)

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8.12.2025 What is the role of a consultant during a virtual review or audit?

Unless a regular operational employee of the organization, a consultant is not to assume responsibility for generating or demonstrating the evidence for Recognition. While external consultants are welcome to be part of the virtual reviews or audit, these calls are led by the appropriate practice team members.  NCQA reserves the right to obtain contact information of consultants working with the practice as well as verify the identity of individuals present during the virtual review or audit.

PCMH

8.12.2025 Which clinicians need to be listed in Q-PASS?

Every qualifying clinician at a practice site is required to be listed in Q-PASS. Clinicians who meet the following three criteria must be listed for each Recognized PCMH site they practice at:

  1. MDs, DOs, PAs and APRNs (including nurse practitioners and clinical nurse specialists) who practice internal medicine, family medicine or pediatrics.
  2. The clinician can be selected by patients as their primary care clinician. 
  3. The clinician has their own or shares a patient panel.

PCMH

8.12.2025 What do we do if a practice has to close temporarily or permanently?

Any structural or operational change must be reported to NCQA. Organizations must contact their NCQA Representative for further instructions within 30 days of the change.

PCMH

7.01.2025 What are the new elective criteria that have been added to the PCMH Standards and Guidelines for Version 11?

Best Practices from NCQA’s Virtual Primary Care Program to PCMH:
The following elective criteria were written during the creation process of the new Virtual Care program, but found to be best practice for all primary care settings. For this reason, nine new elective criteria are added to the PCMH program.
 

Criteria Criteria Title Brief Description
TC 10 Patient Consent The organization requests patient consent to treatment through virtual modalities.
KM 30 Prescribing Patterns The organization tracks medication prescribing practices and performs analysis on prescribing patterns.
KM 31 Interpreter Services The organization uses competent interpreter or bilingual services to communicate with individuals in a language other than English.
KM 32 Virtual Care Training The organization provides staff training on relevant clinical and nonclinical topics.
AC 15 Appropriate Modality of Care The organization has a process for determining that virtual care is appropriate for the patient.
AC16 Information for Appeals The organization provides clinical information in response to appeals of denials based on medical necessity or treatment guidelines.
AC 17 Services Covered by Insurance The organization has a process for informing patients which services are covered by insurance.
QI 20 Assessment of Clinician and Care Team Experience The organization assesses clinician and care team experience for delivering care.
QI 21 Goals and Actions to Improve Clinician and Care Team Experiences The organization identifies at least one opportunity to improve the clinician and care team’s experience, implements an intervention and measures the intervention’s effectiveness.

PCMH 2017

7.01.2025 What are the cadence thresholds that have been added to the PCMH Standards and Guidelines for Version 11?

Cadence Thresholds Added:
Cadence thresholds are applied to 45 criteria to ensure continuous improvement and to avoid stagnation in workflows (i.e. “at least annually").

 

Criteria Title
TC 06: Individual Patient Care Meetings/ Communication
TC 07: Staff Involvement in Quality Improvement
KM 02: Comprehensive Health Assessment
KM 03: Depression Screening
KM 04: Behavioral Health Screenings
KM 05: Oral Health Assessment
KM 06: Predominant Conditions
KM 07: Social Determinants of Health
KM 09: Diversity
KM 11: Population Needs
B. Educates practice staff on health literacy and
C. Educates practice staff in cultural competence.
KM 17: Medication Responses and Barriers
KM 21: Community Resource Needs
KM 23: Oral Health Education
KM 26: Community Resource List
KM 27: Community Resource Assessment
AC 01: Access Needs and Preferences
AC 09: Equity of Access
AC 11: Patient Visits with Clinician/Team
AC 13: Panel Size Review and Management
AC 14: External Panel Review and Reconciliation
CM 01: Identifying Patients for Care Management
CM 02: Monitoring Patients for Care Management
CM 03: Comprehensive Risk Stratification
CM 04: Person-Centered Care Plans
CM 05: Written Care Plans
CM 06: Patient Preferences and Goals
CM 07: Patient Barriers to Goals
CM 08: Self-Management Plan
CM 10: Person-Centered Outcomes Approach
CM 11: PCO: Monitoring and Follow-Up
CC 06: Commonly Used Specialists Identification
CC 07: Performance Information for Specialist Referrals
CC 14: Identifying Unplanned Hospital and ED Visits
QI 03: Appointment Availability Assessment
QI 04: Patient Experience Feedback
QI 05: Health Disparities Assessment
QI 07: Vulnerable Patient Feedback
QI 08: Goals and Actions to Improve Clinical Quality Measures
QI 09: Goals and Actions to Improve Resource Stewardship
QI 10: Goals and Actions to Improve Appointment Availability
QI 11: Goals and Actions to Improve Patient Experience
QI 13: Goals and Actions to Improve Disparities in Care/ Service
QI 15: Reporting Performance Within the Practice
QI 16: Reporting Performance Publicly or With Patients
QI 17: Patient/Family/ Caregiver Involvement in Quality Improvement

PCMH 2017

7.01.2025 What changes were made to the PCMH Standards and Guidelines for Version 11?

KM 02: Comprehensive Health Assessment Added a note, "All patients need all the components addressed in their medical record. Providing components from multiple patients does not meet the intent."
KM 03: Depression Screening Added this clarification in the adolescent section, "Screening under age 12 may be conducted as clinically indicated."
KM 14: Medication Reconciliation and
KM 15: Medication Lists
The thresholds have changed from more than 80% to more than 90%.
KM 26: Community Lists Added, “The practice maintains a list of resources supported by the community and/or payers by selecting five topics or service areas of importance to the patient population.”
AC 01: Access Needs and Preferences Added more detailed information, “The practice annually surveys patients to determine if existing access (e.g., days open, hours of operation, modalities, etc.) is meeting the needs of the patient population. The screening also collects input of the patient to understand their preferences.”
CM 04: Person-Centered Care Plans Clarified that the required elements include the patient’s medication list and management as well as the patient’s comprehensive problem list.
Also, provided more guidance on a care plan’s requirements.
CM 10: Person-Centered Outcomes Approach Added, “If the organization chooses to use PROMs to track goals, NCQA recommends that the organization have at least 8–10 PROMs for clinicians to choose from, for use with patients.”
CC 04: Referral Management Added, “The practice uses the patient's medical health history and clinical protocols to determine when a referral is necessary.”
Also, “The organization confirms that referrals are local to the patient's community of residence, and whether the referral is in the patient's practitioner network.”
Additionally, “The expectation is that the specialist/ancillary clinician return visit documentation so the loop can be closed”
CC 08: Specialist Referral Expectations
And CC 09: Behavioral Health Referral Expectations
Added, “The organization communicates referral expectations to patients, including the contact information of the referring clinician and additional instructions or education, if applicable.”
CC 21: External Electronic Exchange of Information Added D. Clinical data exchange with payers.
This is worth 1 elective credit point.
QI 01: Clinical Quality Measures and
QI 02: Resource Stewardship Measures
Added a documented process to the evidence.
Cadance Thresholds Please see additional FAQ for cadence thresholds, added to 45 existing criteria.

Criteria Retirement:
Eight criteria were identified as no longer serving a substantial purpose or adding meaningful value to primary care, leading to their retirement from the PCMH program.

Criteria Identification and Title
TC 03: External PCMH Collaborations
TC 09: Medical Home Information
KM 08: Patient Materials
KM 18: Controlled Substance Review
KM 25: School/Intervention Agency Engagement
KM 28: Case Conferences
CC 12: Co-Management Arrangements
QI 18: Electronic Submission of Measures

PCMH 2017

7.08.2024 For KM 09, we collect race separate from ethnicity. We do not use the race/ethnicity combination category. Do we need to have “Middle Eastern or North African” options under the race-specific category?

The OMB is requiring “Middle Eastern or North African” for the race/ethnicity combination list. If you do not have “Middle Eastern or North African” as a race only option (if you are collecting race and ethnicity separately), it is ok.

We are instructing practices to work with their vendor to include the “Middle Eastern or North African” option to the combination race/ethnicity category so practices can transition to the OMB race/ethnicity combo for future collection.
 

PCMH

7.08.2024 Can adult practices submit Influenza Immunization or the Pneumococcal Vaccination Status for Older Adults as a custom measure for the immunization category in 2025?

Yes. Adult practices can submit one of these as a custom immunization measure. Since neither of these have 2024 specifications in the eCQI Resource Center, you will need to enter the  numerator/denominator definitions along with your data.
 

PCMH

7.02.2024 July 2024 PCMH Summary of Updates What changes were made to the PCMH Standards and Guidelines for Version 10?

KM 09: Diversity Added “Middle Eastern or North African” to the race/ethnicity combined category.

Also, added this note, “The OMB updated the combined Race and Ethnicity categories in 2024 to include the Middle Eastern or North African population; this is reflected in the publications. If this option is not yet available, work with your vendor to ensure compliance with the OMB.” 

CC 16: Post-Hospital/ED Visit Follow-Up Added a note, "All discharged patients should be contacted, although not every patient may require a follow-up in the primary care practice." 
AR-QI 1: Clinical Quality Measures and AR-QI 2: Resource Stewardship Measures Added this note, “Practices should review measure data before submission, to ensure data are captured accurately and that numbers reflect practice performance and patient population.”
AR-QI 1: CQMs Removed three retired measures. CMS 127: Pneumococcal vaccination status for older adults; CMS 147: Influenza immunization; CMS 161: Adult major depressive disorder: Suicide risk assessment.

Adult practices may submit a custom immunization measure and pediatrics practices must select CMS 117: Childhood immunization status: Combination 10.

Adult practices do not need to submit a request for a custom immunization measure.

AR-QI 1C: Chronic/Acute Clinical Quality Measure Pediatric practices do not need to submit a request via My NCQA to request a custom measure if they were granted a custom chronic/acute measure in 2024.
 
AR-QI 1: CQMs Two new eCQM measures added. CMS 314v1: HIV Viral Suppression (chronic/acute) and CMS 1188v1: Sexually Transmitted Infection Testing for People with HIV (other preventive).
Appendix 6: MAC Policy Changed contact email to rpsig@ncqa.org and removed the mailing address.

PCMH 2017

6.24.2024 Is there a threshold for CMS 68: Documentation of Current Medications in the Medical Record?

No, unless otherwise stated in the specifications, quality measures do not have thresholds that must be met.  

With that said, CMS 68 is similar to KM-15 (core): Maintaining an up-to-date list of medications for more than 80% of patients. Both sets of data require the same action of updating the medication list. However, they differ in that CMS 68 is for patients age 18+ and must be captured at every visit, whereas KM-15 is for all patients at any given time. It is unlikely that there would be a large variance between CMS 68 and KM-15. NCQA requests a note be added in QPASS if CMS 68 differs greatly from KM-15's 80% requirement. This is to provide context to the Review Oversight Committee to better understand your practice and environment. 

If your practice is in Annual Reporting, practices attest that they are in compliance with all core criteria and could provide evidence that they are meeting the more than 80% requirement of KM-15. 

PCMH 2017

3.08.2024 Are providers required to sign-off on care plans?

The request for provider sign-off stems from the ability to verify work has been reviewed by the eligible clinician, and not solely managed by another role within the organization—or externally.

An eligible provider must be able to provide evidence of their involvement in Care Management efforts. They should not be submitting care management efforts they have not directly reviewed. That said, we suggest provider’s sign-off on care plans to indicate that they have reviewed the care plans they are counting towards their CM efforts. 

If there is a systematic limitation–meaning an electronic system does not allow the provider to electronically sign-off on the care plan–an acceptable workaround would be to provide a relevant office visit note(s), a telephone communication note(s), etc. where the provider has documented that the care plan was reviewed, discussed, updated, etc. with the patient. 

Evidence provided should exemplify that the eligible clinician has had direct oversight in care management efforts for the patient. Care planning efforts may be facilitated by other parties within the practice, but the eligible clinician must be an involved participant in the care management efforts included in their CM reporting.

PCMH 2017

2.21.2024 KM 09 Is there a minimum percent threshold for KM 09 (diversity) reporting?

The expectation is that diversity data is collected from all patients in the practice. An overwhelming majority of the practice’s population should have diversity data on file. If this is not the case, the practice should annotate an implementation plan in the notes section of Q-PASS. This plan should include an expected timeline for improved performance.

Please note that diversity data should be collected directly from the patient/family/caregiver. Please refer to the Standards and Guidelines for acceptable response options for each aspect of diversity.
 

PCMH 2017