FAQ Directory: Health Plan Accreditation

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3.17.2025 Delegation Oversight Information Integrity Annual Audit Are organizations required to conduct an annual delegation oversight audit to meet 2025 UM and CR information integrity audit requirements?

No. For standards year 2025 only, NCQA will allow all organizations, regardless of their audit schedule, to submit a detailed implementation plan in lieu of conducting the delegation oversight information integrity audit.    

The implementation plan for each applicable delegate must include:

  • The delegate’s name.
  • The entity conducting the audit (organization or delegate).
    • If the delegate conducts the audit, the implementation plan must include the organization’s plan for review and evaluation of audit findings.
  • The title of staff who conduct the audit.
  • The audit methodology.
  • The audit due date.

Organizations must submit either an information integrity audit report or an audit implementation plan (for selected delegates) at the time of survey submission for the following products:

  • HP: UM 13, Element C, factors 5-7; CR 9, Element C, factors 5-7.
  • CRPN: CR 3, Element C, factors 5-7.
  • UMCRPN: UM 13, Element C, factors 5-7.
  • MBHO: UM 12, Element C, factors 5-7; CR 9, Element C, factors 5-7. 

Organization-level information integrity audits must be conducted, and an implementation plan is not acceptable for the following requirements: 

  • HP: UM 12, Element D; UM 12, Element F, CR 8, Element C.  
  • CRPN: CR 2, Element C.
  • UMCRPN: UM 12, Element D; UM 12, Element F.
  • MBHO: UM 11, Element D; UM 11, Element F; CR 8, Element C.

Note: A related question was posted on 1/15/2025: “Do organizations need to conduct a delegation audit(s) on the 2025 Information Integrity standards within 12 months prior to survey submission date?” This FAQ replaces that post.

This applies to the following Programs and Years:
HP 2025|CRPN 2025|MBHO 2025

3.17.2025 Measure removed from Health Plan Ratings and its impact on QI 3. When calculating the 3.0 average for QI 3, Element B, the FUI measure is included on the Medicare measure list, but was not included on our Health Plan Rating scoring sheet. How do we account for this measure in the calculation?

In the 2024 Health Plan Ratings, Follow-Up After High Intensity Care for Substance Use Disorder (FUI) was removed from the final ratings for the Medicare product line due to insufficient data in MY 2023 HEDIS submissions.

If a measure is not required in the 2024 Health Plan Ratings, it is not required in QI 3. Thus, because FUI was not included in the most recent scoresheet for the Medicare product line, it   is not included in the average calculation in Element B and will not be considered (may not be chosen as a measure to act on) in Element C.

This applies to the following Programs and Years:
HP 2025

2.18.2025 Practitioner credentialing application look-back period for the new practitioner race, ethnicity and language requirement Does NCQA expect organizations to include factor 6 in the application prior to July 1, 2025?

Applications processed before July 1, 2025, will not be held to the factor 6 requirement and will be scored NA.

Applications processed on or after July 1, 2025, will be scored on the factor 6 requirement, but will not be held against the 6-month look-back period until surveys on or after January 1, 2026.

Note: CAQH is updating its credentialing application to include fields for race, ethnicity and language, and a statement regarding anti-discrimination. Updates are scheduled to go live on July 1, 2025.

This applies to:
HPA: CR 3, Element C, factor 6.
CRPN: CRA 3, Element A, factor 6; CRC 10, Element A, factor 6; CRC 11, Element A, factor 6.
MBHO: CR 3, Element C, factor 6.

This applies to the following Programs and Years:
HP 2025|CRPN 2025|MBHO 2025

1.15.2025 2025 Credentialing Standard Changes and Delegation When are organizations required to hold delegates to NCQA’s 2025 credentialing standards? 

Non-file Review Annual Evaluation  

If a survey submission date is on or after July 1, 2025, the organization is assessed against the 2025 Standards and Guidelines, and is expected to hold delegate(s) to 2025 requirements.  

 

File Review Annual Audit 

If a credentialing file audit (CR 9, Element C, factor 2 in HPA/MBHO; CR 3, Element C, factor 2 in CRPN) is scheduled to occur before July 1, 2025, the organization should continue the routine scheduled annual delegation audits for credentialing and recredentialing files, and audit the files against the 2024 credentialing verification time limits.  

If a credentialing file audit is scheduled to occur on or after July 1, 2025, credentialing files processed by the organization’s delegate(s) before July 1, 2025, are assessed against 2024 verification time limits; files processed by the organization’s delegate(s) on or after July 1, 2025, are assessed against 2025 verification time limits.

This applies to the following Programs and Years:
HP 2025|CRPN 2025|MBHO 2025

1.15.2025 CR Information Integrity - Auditing of non-file review credentialing information for inappropriate documentation and updates Do organizations need to audit credentialing meeting minutes and ongoing monitoring reports for all practitioners randomly selected from the file audit universe during the annual credentialing information integrity audit?

Yes. During the audit in CR 8, Element C in HPA/MBHO (CR 2, Element C in CRPN), organizations must review all credentialing information in Element A associated with the selected practitioners’ files. This includes all credentialing verification information, credentialing committee minutes and ongoing monitoring reports.

This applies to the following Programs and Years:
HP 2025|CRPN 2025|MBHO 2025

1.15.2025 Privacy Protections for Data Is access to physical and cloud servers in the scope of the Privacy Protections of Data requirement?

Yes. The intent of LTSS 2, Element B in CM-LTSS (HE 2, Element F in HEA; LTSS 1, Element E in HPA) is that organizations have policies and procedures in place for managing access to and use of race/ethnicity and language data that cover all forms of media, devices and data storage.

This applies to the following Programs and Years:
CM-LTSS 2024|HP 2025

1.15.2025 Define “processed” related to credentialing files Under the verification time limits, NCQA added a note that states the new verification time limits apply to files processed by the organization or its delegate(s) on or after July 1, 2025. Files processed before July 1, 2025, are scored against the previous verification time limits. What does “processed” mean for Health Plan and Credentialing Accreditation and Credentialing Certification?

For Health Plan, MBHO and Credentialing Accreditation, “processed” refers to the credentialing decision date. 

For Credentialing Certification, “processed” refers to the date when credentialing verifications are reported to the client. 

 

This applies to the following Programs and Years:
HP 2025|CRPN 2025|MBHO 2025

12.16.2024 NPDB Acceptable Source for Medicare and Medicaid Exclusions Is the NPDB an acceptable source for Medicare and Medicaid exclusions?

Yes. The NPDB is an acceptable source for both Medicare and Medicaid exclusions.

For Medicaid, organizations must obtain exclusion information from the state Medicaid agency, in addition to either of the following sources:

  • NPDB, or
  • List of Excluded Individuals and Entities maintained by OIG and available over the internet).

For Medicare, organizations may obtain exclusion information from any of the NCQA acceptable sources.

This applies to the following Programs and Years:
HP 2025|CRPN 2025

12.16.2024 MMP Plans CMS intends to dissolve Medicare-Medicaid Plan (MMP) contracts in 2026. Will that change product line rules for Accreditation?

No. Plans that are responsible for both the Medicare and Medicaid components for dual-eligible members may select Medicare, Medicaid, or both, for Accreditation purposes. 

This applies to the following Programs and Years:
HP 2025

12.16.2024 Reviewer Names on Denial and Appeal Notifications Does NCQA require names or signatures of the reviewers on UM denial and appeal notifications?

No. NCQA does not require names or signatures of the reviewers on UM denial and appeal notifications. Please refer to UM 4, Element C and UM 9, Element D for documentation requirements.

This applies to the following Programs and Years:
HP 2025

12.16.2024 Sources for Medicare Sanctions Are organizations required to verify Medicare sanctions from all of the following sources?
• AMA Physician Master File.
• FSMB.
• NPDB.
• SAM.gov.

No. The requirement is that organizations verify Medicare sanctions from any of those sources, but there is no requirement to verify sanctions from all of them. 

This applies to the following Programs and Years:
HP 2025|CRPN 2025

11.15.2024 Verification of Medicare and Medicaid Sanctions and Exclusions Are organizations only required to verify Medicare and Medicaid sanctions and exclusions for practitioners who only provide services for members in the organization’s Medicare and Medicaid product lines?

No. Verification of sanctions and exclusions are not product line–specific requirements. For each practitioner in the scope of credentialing, the organization must verify Medicare and Medicaid sanctions regardless of the product line for which practitioners are contracted.

This applies to the following Programs and Years:
HP 2025