FAQ Directory: Long-Term Services and Supports Distinction for Health Plans

Filter Results
  • Save
  • Email
  • Print
expand all

8.15.2025 Prioritizing Case Management Goals Can multiple case management goals be assigned the same priority level, such as “high”?

Yes, multiple goals can be assigned the same priority level (e.g., “high”), but the organization must still clarify the relative importance of each goal within the same assigned level. The intent of prioritization is to show how goals compare to one another in terms of urgency or importance.

For example, if three goals are all marked “high,” the organization must indicate which of those is the highest priority, second highest, and so on.

This applies to:
HPA: PHM 5, Element E
MBHO: QI 8, Element I
CM: CM 4, Element B
CM-LTSS: LTSS 3, Element C

HP 2026

8.15.2025 UM Information Integrity Audit File Universe The denial and appeal Information Integrity audit universe specifies decisions (based on the notification date) made during the look-back period. Does the audit include data (decision notifications) from outside the look-back period?

Yes. When an organization conducts its UM Information Integrity audit, the audit universe includes data from the most recent 12 months from the timing of the audit. So, although the audit occurs within the look-back period, data reviewed may  include decision notification files from outside the formal look-back window, depending on timing. 

HP 2026

7.15.2025 Obtaining Sanction and Exclusion information from the State Agency Some State Medicaid agencies do not provide both sanction and exclusion information. What does NCQA expect in this situation?

The organization must provide documentation from the agency confirming that it does not provide sanction/exclusion information. If the state agency declines to supply written confirmation, the organization documents its effort to obtain the information.  

The organization must verify Medicaid sanctions and exclusions from one of the additional sources specified in the standards and guidelines. The credentialing file must include evidence of both the unavailability of the information from the state agency and verification from an approved additional source. 

Applicable Standards: 

HPA: CR 3, Element B; CR 5, Element A 

CRPN: CRA 4, Element B; CRA 5, Element A; CRC 9, Element A; CRC 12, Elements B and C 

MBHO: CR 3, Element B; CR 5, Element A 

HP 2025

7.15.2025 Acceptable Titles for Reviewers The explanation for UM 9, Element D, factor 5 specifies that the reviewer's title is their position or role in the organization. How does the organization document this for external reviewers?

If a reviewer is external to the organization, the title/role must reflect it (e.g., “External Reviewer,” “External Independent Reviewer”). 

HP 2025

6.16.2025 Clarifying the Definition of “Threshold Languages” How does NCQA define “threshold languages” for CM-LTSS Accreditation and LTSS Distinction in Health Plan Accreditation?

NCQA defines threshold languages as “all languages other than English spoken by 5% of the population or by 1,000 eligible individuals, whichever is less.” 

Applicable Standards: 

HP: LTSS 1, Element D, factor 2. 

CM-LTSS: LTSS 2, Element A, factor 2. 

HP 2025

6.16.2025 Conducting Audit of Effectiveness Quarterly If an organization chooses to complete its audit and analysis for the Information Integrity requirements quarterly, may it also complete the audit of effectiveness quarterly?

Yes. Organizations that choose to conduct their audit and analysis for Information Integrity more frequently than annually (i.e., quarterly), may also conduct the follow-up audit of effectiveness more frequently. The audit must be within the 3–6 month time frame prescribed by NCQA. 

Applicable Standards: 

HP: CR 8, Element C; CR 8, Element D, factor 2. UM 12, Element D, UM 12, Element E, factor 2; UM 12, Element F, UM 12, Element G, factor 2. 

CRPN: CR 2, Element C, CR 2, Element D, factor 2. 

MBHO: CR 8, Element C; CR 8, Element D, factor 2. UM 11, Element D, UM 11, Element E, factor 2; UM 11, Element F, UM 11, Element G, factor 2. 

HP 2025

6.16.2025 Evidence for QI 3, Element D: Exchange Reporting What types of evidence may an organization submit to demonstrate reporting of the required measures for QI 3, Element D?

Organizations must provide an IDSS report and/or a CMS Proof Sheet as evidence of reporting the required measures for the Exchange product line in QI 3, Element D.

HP 2025

6.16.2025 QI 3, Element A: Applicability of Behavioral Healthcare Reported Measures How can an organization that reports measures for QI 3, Element A meet the 50% threshold if behavioral healthcare services are carved out and the organization therefore has a “No Benefit” audit designation for 6 of the 10 measures? 

In this example, the organization may demonstrate compliance with QI 3, Element A by providing evidence that it reported 50% of required measures it is capable of reporting. The organization would be required to report a valid, numeric rate for at least 50% of the required nonbehavioral health measures (i.e., 2 of the 4).

HP 2025

5.15.2025 CAQH Application and Antidiscrimination Statement Has NCQA been in communication with CAQH about including the new NCQA requirements for race, ethnicity and language on its application?

Yes. NCQA has worked with CAQH to add a notice to its practitioner- and customer-facing provider credentialing applications, recognizing that discriminatory uses of race, ethnicity and language data are prohibited. CAQH is going live with the application update on 7/1/25.

The use of the CAQH application will be acceptable to meet CR 3, Element C, factor 6: Race, ethnicity and language in the 2025 Health Plan Accreditation standards and guidelines (and applicable products).

This applies to:
HPA: CR 3, Element A, factor 6
CRPN: CRA 3, Element A, factor 6, CRC 10, Elements A, factor 6
MBHO: CR 3, Element A, factor 6

HP 2025

5.15.2025 Credentialing Application: Race, Ethnicity and Language (REL) Are separate fields required for race, ethnicity and language? For example, is the CAQH application acceptable to meet CR 3, Element C, factor 6, as the CAQH application collects race and ethnicity under one field and language in another?

The requirement is for the application to have separate fields to enter responses for each of these three data points (race, ethnicity, and language). However, it would be acceptable to group these into one question if the application prompts the user to provide separate responses for race, ethnicity and language. 

Responses provided through the CAQH online portal for credentialing data application are acceptable. Although the online portal supporting the credentialing application groups the responses for race and ethnicity into one field, the practitioner is prompted to provide separate responses within the system. When a practitioner chooses his/her race, the practitioner is then prompted to provide his/her ethnicity information. Language is captured via a separate field.  

This applies to:
HPA: CR 3, Element A, factor 6
CRPN: CRA 3, Element A, factor 6, CRC 10, Elements A, factor 6
MBHO: CR 3, Element A, factor 6

Note:  A related question was posted on 3/17/2025: “Credentialing Application: Race, Ethnicity and Language (REL).” This FAQ is an update to that post. 

HP 2025

4.15.2025 Using software to make medical necessity approval decisions May organizations use software to make medical necessity approval decisions?

Yes, if the software uses the organization’s clinical criteria, policies and procedures and benefit package information, and the organization maintains control over the software implementation. Organizations may not use the software to make any denial decisions; those must be made by an appropriate clinical professional. Appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.

NCQA considers the use of external software to make approval decisions to be a vendor relationship for applicable requirements (e.g., UM 4, Element F). Refer to Appendix 3: Delegation and Automatic Credit Guidelines for additional information.

HP 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.

HP 2025