FAQ Directory: Health Plan Accreditation

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5.15.2020 UM 5: Medicaid lookback period For Renewal Surveys, the look-back period is specified as 6 months for the Medicaid product line in UM 5, Elements A-C. Is this correct?

No. The look-back period should be specified as 12 months for all product lines, for Renewal Surveys, which is consistent with the other file review standards and elements. NCQA initially changed the scope of review to account for a change made to verbal notification and how it no longer affords organizations an extension.

However, because of this error, if an organization does not meet a factor in UM 5, Elements A-C within the first 6 months of the look-back period, NCQA does not penalize the organization and scores the file “NA” instead of “Not Met” for Medicaid surveys.

HP 2020

4.15.2020 Update: Practitioner Involvement and Adoption of UM Criteria For UM 2, Element A, factor 4, when an organization develops or adopts UM criteria, may it limit involvement of practitioners to practitioners who are organization staff, even if they are also network practitioners?

The answer posted in March 2020 unintentionally increased the rigor of the requirement for the 2020 standards year. Therefore, we are updating the answer.
For the 2020 standards year, organizations may limit involvement to practitioners who are staff or participants in the network; NCQA does not require non-staff network practitioners to be involved.

Effective for the 2021 standards year, organizations may not limit involvement to practitioners who are staff. Non-staff network practitioners must also be involved in developing, adopting and reviewing criteria, because they are subject to application of the criteria. If an organization has been unable to involve network practitioners, it must document its attempts and provide the documentation to NCQA during the survey.

This change will be released in the 2021 standards and guidelines.

HP 2020

4.15.2020 LTSS 1, Element G: HEDIS Measure The November 2019 Policy Update change to LTSS 1, Element G specifies that the Comprehensive Assessment and Update (LTSS-CAU) measure may be used instead of completing the file review. Is this correct?

No. Replace “LTSS-CAU” with “LTSS-CPU“ (Comprehensive Care Plan and Update). Performance results of LTSS-CPU may be used instead of completing the file review.

HP 2020

3.26.2020 Guidance and Exceptions to NCQA Programs Regarding Coronavirus Has NCQA issued guidance about exceptions or modifications to NCQA programs and requirements in response to the coronavirus?

Yes. NCQA posted guidance for HEDIS reporting and Accreditation/Recognition programs at https://www.ncqa.org/covid/. NCQA is monitoring the effects of the coronavirus on our customers; we will adjust requirements as circumstances warrant. Please continue to check this website frequently as the situation continues to evolve.


HP 2019

3.15.2020 36-month Recredentialing time frame Does NCQA allow an organization to extend the 36-month recredentialing time frame if it failed to credential a practitioner on time?

No. Except as noted under “Related information: Extending the recredentialing cycle length,” where NCQA makes provisions for situations such as active duty military assignment and medical leave, the organization may not extend the 36-month recredentialing cycle. If the practitioner is not recredentialed within 36 months, the file will be scored down. There is no grace period for recredentialing.
If an organization missed the recredentialing deadline and intends to keep the practitioner in the network, files must be processed as follows:

  • If the organization can complete the credentialing process within 30 days of the original due date, it may recredential the practitioner (e.g., the organization need not verify credentials required only at initial credentialing). The organization must complete the process and make the credentialing decision within 30 days of the original credentialing due date.
  • If the organization cannot complete the credentialing process within 30 calendar days of the original recredentialing due date, it must take the practitioner through the initial credentialing process.

HP 2019

3.15.2020 Clarifying HPA 2020 Scoring with File Review Scoring Question Please explain “PARTIALLY MET” for scoring that reads “High (90-100%) or medium (60-89%) on file review for X factors” in file review elements (e.g., PHM 5, Element D)?

Interpret that text to mean any combination of high and medium other than the scoring thresholds specified for “MET.”
For example, an organization must earn “high” on 7 factors to score MET on PHM 5, Element D; therefore, to score “PARTIALLY MET” for that element, it may earn “high” on 0–6 factors and “medium” on the remaining factors.

HP 2020

3.15.2020 PHM 3, Element B: Value Based Payment Arrangements Does NCQA require organizations to have more than one type (e.g., pay-for-performance, shared savings) of value-based payment arrangement per product line?

No. An organization meets the requirement if it has at least one VBP of any type per product line. Organizations may report more than one VBP arrangement per product line but are not required to do so.

HP 2020

3.15.2020 Using Complaint Data to Supplement Surveys or Self-Reported Information In NET 2, Elements A–C, if an organization collects data using surveys or practitioner self-reported information, it must supplement the data with an analysis of complaints regarding access. Are organizations required to conduct a complete quantitative and qualitative analysis of complaint data?

No. Supplemental complaint data validates survey findings and self-reported information and assists in qualitative analysis of primary data. The organization is not required to conduct complete quantitative and qualitative analysis of supplemental data.

HP 2020

3.15.2020 PHM 3, Element A, Factor 3: Practice transformation support Does reporting a physician’s designation or status as “integrated or advanced” practice in a web-based physician directory meet the requirement to support practice transformation?

No. Publicly reporting a practice’s designation or status does not constitute “active support.” Organizations may actively support transformation through financial incentives, learning collaboratives, MOC credits and other methods.

HP 2020

2.15.2020 UM Timeliness Report Under 2020 HPA standards, UM 5, Element D requires organizations to monitor UM decision making and notification using UM 5 decision time frames, even though UM 5, Elements A, C and E were eliminated under the 2020 standards. Is this correct?

Yes, it is correct. The elimination of Elements A, C and E does not affect the review of Element D: UM Timeliness Report. The expectation is that the report includes timeliness for both decision making and notification of the decision given that the report includes denials and approvals. NCQA does not require written notification for approvals; therefore, timeliness for approvals is only reported under decisions.

HP 2020

2.15.2020 Measure Validity The explanation in Element A in QI 3 and QI 4 does not require that data collected results be valid or reliable measures; however, the explanation for Element C in QI 3 and QI 4 states that the organization must describe its methodology (numerator, denominator, sampling, measurement periods). Does NCQA review the validity and reliability of measure results in either Element A or C?

NCQA does not evaluate the validity or reliability of the measure in Element A, QI 3 and QI 4. In Element C, QI 3 and QI 4, NCQA evaluates the validity of the remeasurement relative to the initial measurement. For example, NCQA evaluates if sampling, timing or other methodological factors introduces bias or other issues of comparison when determining an intervention’s effectiveness.

HP 2020

1.15.2020 Denial Notifications to members via web portals If an organization uses a member web portal as a means of member written/electronic denial notification (which includes all requirements of UM 4 through UM 7), does this meet the UM denial notification requirements?

No, notification of denials to a member through a web portal does not meet the requirement for member notifications. However, emailing a denial notification directly to a member would be acceptable for electronic notification.

HP 2020