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Annual Reporting for PCSP Recognition

Annual Reporting helps practices strengthen by reviewing progress and encouraging performance improvement more frequently.

As part of maintaining your recognition, each year practices undergo an Annual Reporting process. This is a different process than how you previously renewed NCQA PCSP Recognition. You will attest to continuing to meet criteria and submit data and documentation. This new process is not as involved as initial recognition, but it maintains a practice’s recognition and encourages continuous improvement.

When Does Annual Reporting Begin?

Your Annual Reporting date is 30 days prior to your recognition anniversary date. All Annual Reporting data and documentation must be submitted no later than 30 days prior to your recognition expiration date. Practices that are a part of a multi-site organization share the same Annual Reporting date, unless otherwise requested. The Annual Reporting date is based on the date the first practice achieves recognition.

What Will I be Asked to Do?

Annual Reporting requirements are flexible. You are probably performing the required tasks already as a recognized practice, so you will just need to show us what you are currently doing.

Practices are asked to:

  • Attest that they continue to meet requirements and perform a self-assessment to verify that they have continued core activities of your recognition program.
  • Demonstrate that they are embracing measurement and quality improvement. In some cases, practices must submit evidence using the Q-PASS system.
  • Provide measurement data, if necessary.

See the requirements and options for Annual Reporting, download the Annual Reporting requirements.

What Information Will I Need to Show NCQA?

Practices must submit data and documentation that cover the 7 concepts, and must meet the minimum number of requirements for each category. The 7 areas include:

  1. Team-Based Care and Practice Organization
  2. Initial Referral Management
  3. Knowing and Managing Your Patients
  4. Patient-Centered Access and Continuity
  5. Plan and Manage Care
  6. Care Coordination and Care Transitions
  7. Performance Measurement and Quality Improvement

How to Prepare for Annual Reporting

Embrace Patient-Centered Care and Quality Improvement.

After you earn recognition, continue to embrace the patient-centered model and activities. Continue your quality improvement and performance measurement efforts. This will help during next year’s Annual Reporting.

Know What is Required.

Download the Annual Reporting requirements. Look at what’s expected after recognition.

Plan Ahead.

Identify the requirements to submit ahead of time. Some requirements have a list of options that the practice may choose. Discussing and selecting submission options will help your team create work plans and will help your practice perform well throughout the year.

Upload Data at Any Time.

Don’t wait until the month before your anniversary to add data to Q-PASS. You can upload and enter—or submit—Annual Reporting requirements at any time during the year. If you can build submission into existing processes, it becomes part of your quality improvement activities.

Annual Reporting Requirements Timeline and Checklist

Date GuidanceTask
July prior to the reporting yearNCQA releases the next year's requirement. Go to NCQA eStore and download the Annual Reporting Requirements.
6-9 months before Annual Reporting Date1. Review Annual Reporting.Requirements
2. For concepts with options, select the option for the which your like to submit.
3. Start gathering evidence for Annual Reporting requirements.
4. Perform tasks in Q-PASS:
- Confirm clinicians and practice information.
- Upload documents and enter data to meet requirements.
- Pay the Annual Reporting fee.
Annual Reporting Date (1 month before Anniversary Date)Submit Annual Reporting requirements.

How to Submit Your Annual Reporting Requirements

The entire recognition process is now managed through the Q-PASS system. You will use this system to upload documentation; track progress; manage practice sites, clinicians and recognition; and pay recognition fees.

  • Log into Q-PASS with your login information from your My NCQA account. Claim your organization and update/confirm your organization information.
  • Enroll in Annual Reporting through Q-PASS and make payment. Once you enroll, practices are assigned an NCQA representative who can be emailed with questions about the process.
  • Submit documentation, evidence and data via Q-PASS.
  • NCQA reviews your submission and notifies your practice that you have earned recognition.
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