FAQ Directory: Patient-Centered Medical Home (PCMH)

Filter Results
  • Save

    Save your favorite pages and receive notifications whenever they’re updated.

    You will be prompted to log in to your NCQA account.

  • Email

    Share this page with a friend or colleague by Email.

    We do not share your information with third parties.

  • Print

    Print this page.

4.01.2022 Is a minimum reporting period required for measures?

NCQA recommends using the previous calendar year (January 1–December 31) when possible. If there is not a calendar year of data, the practice may submit the reporting period it uses to regularly monitor performance.  

PCMH 2017

4.01.2022 Is there a minimum denominator requirement when reporting a rate for Annual Reporting?

No. There is no minimum denominator requirement. A sample of 30 (or more, because this increases the reliability of the sample) is required to ensure statistical soundness, but there may be cases where it may be appropriate for the denominator to be <30. NCQA requests practices enter an explanation in the Notes from the Organization section in QPASS in this case.

If a practice reports a denominator <30 without a note, the evaluator may contact the practice to confirm data accuracy and to understand the data. The evaluation will be returned to the practice so they can enter an explanation in the Notes from the Organization section for the cited criteria.

PCMH 2017

4.01.2022 For AR-KM 1: Medication Lists (aligns with PCMH KM 15), is a reported rate <80% automatically marked as “Not Met”?

Yes. AR-KM 1 confirms that practices meet PCMH KM 15, in which more than 80% compliance is required for medication lists. A rate less than or equal to 80% does not meet criteria.

PCMH 2017

4.01.2022 Is there a minimum threshold requirement when reporting a rate for Annual Reporting?

It depends. If the AR requirement aligns with a PCMH criteria that specifies a threshold, then that value would be the minimum threshold. However, if a threshold is not explicitly stated in the criteria, then a threshold of 80% or more is expected to ensure consistent application of the process. Please note that there may be some cases where it’s acceptable for the rate to fall below 80%. 
An explanation is required for practices that report a rate less than 80% for the following criteria: AR-AC 1, AR-AC 2, AR-CC 3 [Tracking Imaging Results], and AR-CC 3 [Tracking Lab Results]. 
Additionally, this threshold requirement of 80% would also apply if a practice chooses to submit a depression screening measure for AR-QI 1.

PCMH 2017

4.01.2022 When do I need to add additional information about the measure performance?

Practices should submit an explanation when their performance falls below 80% for the following AR criteria: 
•    AR-AC 1: Timely Clinical Advice by Telephone
•    AR-AC 2:  Patient Visits with Clinician/Team
•    AR-CC 3 (Option): Lab and Imaging Test Tracking (2 rates)
•    AR-QI 1: Depression Screening and Follow-Up (if selected)
Practices should submit an explanation when their performance falls below 30% for the following AR criteria: 
•    AR-CC 4: Referral Tracking. 
If the practice does not submit an explanation, NCQA will contact the practice. 

PCMH 2017

4.01.2022 AR CC 4 For AR CC 4: Referral Tracking (aligns with PCMH CC 11), must practices meet a percentage threshold to meet criteria?

No. There is no percentage threshold for referral tracking measures. The expectation is that practices track important referrals routinely; if performance is lower than expected, NCQA contacts the practice. For example, if data show a 30% return rate, that means 70% of the practice’s referred patients never had a report returned to their PCP. In such instances, the evaluator may contact the practice to understand the circumstances for the low return rate.

PCMH 2017

4.01.2022 Why do I need to provide more information for a low denominator or rate if there is no minimum requirement?

It is to ensure patient safety and routine implementation of medical home activities. Depending on the population served and/or the reporting period, a small denominator is unexpected and may indicate issues (e.g., with data, documentation, implementation). Providing additional information allows the practice to explain—beyond the numbers—when performance is outside the expected range.

PCMH 2017

6.29.2021 July 2021 Summary of Updates What changes were made to the PCMH Standards and Guidelines in Version 7?

TopicUpdate Highlights
Policies and ProceduresAdded a section on Natural Disasters and Cybercrime.
Policies and ProceduresUpdated policy on eligibility to clarify that organizations that operate entirely remotely are eligible.
Appendix 2 – GlossaryAdded an entry on Behavioral Health Care Clinician.
TC 08/BH 01Added a note to the guidance language to clarify the required qualifications of a Behavioral Health Care Manager.
KM 20/BH 13Updated the list of CDS examples in the guidance language.
AC 04Added language to the guidance to clarify that patient inquiries regarding prescription refills or appointment requests are not considered clinical advice.
CM 06Updated guidance language to detail how Person-Driven Outcome goals can be used to meet the criteria.
QI 01/ QI 02Measures data must be input from the new ‘Measures Reporting’ tile of the Organization Dashboard.
Appendix 5Redesigned Appendix 5 to outline measures reporting including a table of standardized measures now supported.
Distinction in Behavioral Health IntegrationClarified that already Recognized practices seeking Distinction have one virtual review.

PCMH 2017

6.25.2020 July 2020 PCMH Summary of Changes What changes were made to the PCMH Standards and Guidelines?

PCMH (Version 6) Summary of Changes
TopicUpdate Highlights
Standards and Guidelines / Appendix 7The New York State PCMH program was integrated into the PCMH Standards and Guidelines and is no longer a separate publication. The ‘NYS’ icon was added to all 12 required criteria for NYS PCMH. The new Appendix 7,  NYS PCMH Recognition Program, outlines the specifics of the NYS program.
Standards and GuidelinesAdded the ‘Site-Specific’ and ‘Cross-Program Shared Credit Option’ symbols to all relevant criteria.
Standards and Guidelines/ Appendix 6The new appendix outlines the updated Merger, Acquisition and Consolidation Policy for Recognition Programs policy.
TC 03Updated language describing an appropriate external PCMH collaborative and clarified than participation in an HIE will not meet the requirement.
TC 08Highlighted the behavioral healthcare manager may conduct their duties through telehealth.
TC 09Specified that if appointments are conducted using telehealth, the practice should have a process for informing patients about the availability.
KM 04Clarified that the practice must use a standardized screening tool and have a process for following up on results.
KM 05Clarified that asking patients for the date of their last dental exam or providing a list of local dentists does not meet the intent of the criterion.
KM 09Specified that age and gender are not acceptable as a third aspect of diversity.
KM 11ASpecified that the identification of a disparity in care/service for a vulnerable group should be driven by the practice’s data and compared to the general practice population. Actions taken to reduce the disparity should be specific to that vulnerable group.
KM 13Specified that excellence in a performance-based recognition programs must be at the site level.
AC 01Specified that AC 01 focuses on assessing patient access needs and preferences specific to appointments. Also clarified that this differs from more general patient experience assessment of access in QI 04.
AC 02-AC 03Highlighted that same-day appointments and after-hours appointments may be conducted through telehealth.
AC 03Clarified that an ED cannot be used to provide appointments outside business hours.
AC 04 and AC 08Clarified that the report includes calls or messages received both during and after office hours.
AC 05Specified that clinical advice documentation is inclusive of telehealth appointments.
AC 06Clarified that disease specific appointments, home visits and group visits do not meet the intent of the criterion.
AC 12Stated that continuity of the medical record is inclusive of telehealth appointments.
CM 02Specified that small sites and satellite sites may share a care management population with NCQA approval.
CM 03Specified that comprehensive risk stratification must include at least 3 of the categories outlined in CM 01.
CM 04 – CM 08Specified that care plans must be established for at least 75% of patients identified for care management.
CC 09Clarified that the agreement may be with a contracted behavioral telehealth provider.
CC 10Clarified that behavioral health integration may be done through behavioral telehealth.
CC 13

Clarified and updated the expectations for engagement regarding cost implications of treatments options. Practices should not only engage with patients regarding cost implications of treatment options, but also provide information about current coverage and make connections to financial resources as needed.

CC 16Highlighted that follow-up visits may be conducted through telehealth.
CC 21Clarified that electronically exchanging information should include data both sent and received.
QI 04BClarified that the report provided should summarize collected feedback.
QI 05Updated the vulnerable patient population definition.
QI 01 and QI 02Clarified that measures include activities conducted during telehealth visits.
QI 03Specified that major appointments may be conducted in person or via telehealth.
QI 04Clarified that the access category may include questions regarding telehealth.
Policies and ProceduresAdded a description of telehealth in NCQA recognition programs.
Policies and ProceduresUpdated the reconsideration process.
Policies and ProceduresThe “Discretionary Audit” is now called the “Discretionary Review”.


PCMH 2017

4.07.2020 TC 04 & QI 17 Can a large organization meet TC 04 and QI 17 through a shared Patient and Family Advisory Council (PFAC)?

Organizations may share a Patient and Family Advisory Council (PFAC) among sites as long as every site has representation on the council. Large organizations with many sites may consider creating multiple PFACs based on region or clinic type.

PCMH 2017

4.07.2020 QI 11 May a practice use qualitative feedback to meet QI 11?

To meet criterion QI 11 a practice must first establish a baseline for a patient experience measure and then set goals and take actions to improve upon this measure. Qualitative measures can be used if the qualitative feedback can be measured and the baseline can be compared to any improvement. An example of this may be the practice trying to reduce the total number of negative feedback responses they receive through a suggestion box pertaining to wait times by 50%.

PCMH 2017

4.07.2020 KM 13 Do benchmarked/ performance-based recognition programs at the organization or health system level meet KM 13?

No, organization or health system involvement in a benchmarked/ performance-based recognition program will not meet. For KM 13, the practice must participate in an external recognition program that assesses the practice or clinician-level performance, using a common set of specifications to benchmark results. The external recognition program should also publicly report results and have a process to validate measure integrity.

PCMH 2017