Save your favorite pages and receive notifications whenever they’re updated.
You will be prompted to log in to your NCQA account.
Save your favorite pages and receive notifications whenever they’re updated.
You will be prompted to log in to your NCQA account.
Share this page with a friend or colleague by Email.
We do not share your information with third parties.
Share this page with a friend or colleague by Email.
We do not share your information with third parties.
Print this page.
Print this page.
No. Organizations must use 12 months of continuous data and may use data from the most recent calendar year (e.g., January 1–December 31). The workbook must be completed at least once during the look-back period.
Applicable standards:
UM Information Integrity oversight requirements related to UM request receipt and UM decision notification dates may be scored Not Applicable (NA) for delegates that only perform approvals and/or recommendations. Please note that this exception does not apply to delegates that make denial decisions.
Factors 5–7 are limited to the evaluation of UM receipt and notification dates.
Applicable standards:
No. For NCQA Health Plan Accreditation, NCQA reviews and scores UM 1, Elements B–H separately for each product line brought forward for Accreditation. Organizations may not combine any product lines—including commercial and Exchange—when reporting and evaluating UM rates for UM 1, Elements B–H.
Applicable standards:
If delegates that render medical necessity determinations do not have access to, manage, or handle UM request receipt dates or UM decision notification dates for any client—and no receipt or notification dates are stored in the delegates’ systems—then UM 12, Element C, factors 5–7 may be scored Not Applicable (NA), because the intent of these factors is to evaluate the integrity of receipt and notification dates.
If an organization retains sole responsibility for receiving UM requests, documenting receipt dates, and issuing UM decision notifications—and its delegates render medical necessity determinations only—then UM 12, Element C, factors 5–7 do not apply to those delegates.
Applicable standards:
No. Automation is evaluated and scored in PHM 5, Element B, and is not scored in PHM 5, Element D. Dates and timeliness are evaluated and scored for each factor in PHM 5, Element D.
For PHM 5, Element D:
If all components are completed at one time, one date is sufficient.
If the components are completed at different times, the system must automatically capture the date associated with each factor in Element D.
Note: A related question was posted on January 15, 2026: “Automated documentation of dates in PHM 5, Element D.” This FAQ replaces that post.
Applicable standards:
Health Plan Accreditation: PHM 5, Element D
Yes. For the 2026 standard year only (surveys conducted between July 1, 2026, and June 30, 2027), NCQA will allow organizations to submit a detailed implementation plan.
The plan must include:
Look-Back Period: Effective immediately, the look-back period for the entire Element B for First Surveys and Renewal Surveys has changed from six months to “prior to the survey date.”
This approach provides flexibility and additional time for organizations to meet requirements.
Applicable Standards:
Yes. Data from UM delegates must be included in the UM denial and appeal rates reported for UM 1, Elements B-E (in Health Plan Accreditation). The intent of reporting the rates for these elements is to provide a comprehensive view of the organization’s UM denial and appeal rates. Therefore, the expectation is that the organization presents all rates in a single workbook, rather than separating requests received by the organization (e.g., health plan) and those received by the delegate.
Applicable standards:
No. QI 2, Element C does not require bidirectional data sharing.
The intent of the requirement is for health plans to share data required for at least one HEDIS measure identified in QI 2, Element C. This enables behavioral health organizations to collect HEDIS measure data to meet NCQA’s Behavioral Health Accreditation program requirements. The health plan and the behavioral health entity collaboratively select the specific HEDIS measure(s), review the technical specifications outlined in Volume 2, and determine which data elements need to be shared to support accurate and efficient reporting.
No. Organizations must use the exact calculated average to determine the element score. Rounding is not allowed.
For example, a calculated average of 2.8 does not meet the required threshold of 3.0, and the element is scored “Partially Met.”
NCQA updated the look-back period on the Medi-Cal Rx Crosswalk for UM 11, Element E to be “prior to the survey date” for the 2025 standards year. This applies to California Medicaid organizations only.
The look-back period should read:
For Interim Surveys: Prior to the survey date for all Elements.
For First Surveys: 6 months for Elements A-D; prior to the survey date for Element E.
For Renewal Surveys: 12 months for Elements A and C; at least once during the prior year for Elements B and D; prior to the survey date for Element E.
No. Effective immediately for delegation oversight standards, organizations receive automatic credit for the delegation agreement semiannual reporting requirement in Element A, and for the delegation oversight semiannual report evaluation in Element C, when an NCQA-Accredited/Certified delegate performs an NCQA-required activity.
For example, in Health Plan Accreditation, NET 6, Element A, factor 3 and NET 6, Element C, factor 3 receive automatic credit for an NCQA-Accredited/Certified delegate.
This applies to all products.
Note: This updated FAQ replaces the original version published on September 15, 2025.
