Annual Reporting for NYS PCMH Recognition

As part of maintaining NYS PCMH Recognition each year, practices undergo an Annual Reporting process. This demonstrates that your ongoing activities are consistent with the PCMH model of care. You will attest to continuing to meet PCMH 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 requirements (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 PCMH and will only need to show NCQA what you are currently doing. Practices are asked to:

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

To 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 6 PCMH concepts. Practices must meet the minimum number of requirements for each category. The 6 areas include:

1. Patient-Centered Access
2. Team-Based Care
3. Population Health Management
4. Care Management
5. Care Coordination and Care Transitions
6. Performance Measurement and Quality Improvement

Practices are also required to submit data and documentation for 12 additional criteria required by New York state.

How to Prepare for Annual Reporting

Embrace PCMH and quality improvement.

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

Know what’s 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.

Submit in stages.

Don’t wait until the month before your anniversary to submit. 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

StepDescriptionTime Before Recognition
Recognition Learning the NYS PCMH Annual Reporting RequirementsDownload the NYS PCMH Annual Reporting Requirements needed to sustain your PCMH Recognition. Requirements change from year to year. Be sure to download the requirements for the year of your first Annual Report.6-9 months
Determine which Annual Reporting requirements you want to submit forEnsure your practice is aligned with the Annual Reporting requirements. You will attest to continuing to meet the current PCMH requirements without providing the evidence required of practices seeking recognition for the first time. You will also show evidence you meet the additional NYS PCMH required criteria and submit key data and documentation to verify that your practice meets the core features of the medical home.6-9 months
Find a Transformation Assistance ContractorNew York offers Transformation Assistance Contractors to support your practice at no cost to your organization. Find a list of contractors here.6-9 months
Log into Q-PASSYou will need to claim your organization in Q-PASS to get started. Please note: Multi-site accounts should contact NCQA in advance through My NCQA.4 months
Update/confirm organization informationUpdate/confirm organizational information in Q-PASS. In Q-PASS you can update clinician information, contact information, change addresses and add users to your account.4 months
Enroll through Q-PASSThis starts the Annual Reporting process. Please be sure to have your required code to enroll in NYS PCMH. If you were part of New York’s Advanced Primary Care program, request this code from a Technical Assistance Contractor. If you were not part of New York's APC program, your code is "GNYDOC". NOTE: Enroll at least 3 months prior to your recognition expiration date. All Annual Reporting requirements (data and documentation) must be submitted no later than 30 days prior to your recognition expiration date.3+ months
Connect with Your NCQA RepresentativeYou will be assigned an NCQA Representative who will be available to assist you with educational resources and answers to your questions.3 months
Upload EvidenceDemonstrate that you are embracing measurement and quality improvement. Submit documentation and data via Q-PASS.1+ months
Earn RecognitionNCQA notifies your practice of its NYS PCMH Recognition status. 0 months
Print Your Recognition CertificateOnce notified of recognition, go into Q-PASS and print Recognition Certificate (from the My Evaluation screen in Q-PASS). 0 months
Annual ReportingYour practice performs ongoing quality improvement and submits evidence of this during Annual Reporting to sustain NCQA recognition and succeed as a NYS PCMH.11 months after your recognition date (1 month prior to anniversary date)
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