FAQ Directory: Managed Behavioral Healthcare Organization Accreditation

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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.

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.

MBHO 2025

10.15.2024 Hurricanes and other Natural Disasters Does NCQA make accommodations for organizations that have been impacted by a natural disaster and experienced a disruption in operations?

NCQA makes disaster accommodations on a case-by-case basis during the accreditation survey process.

The organization must document the events from the disaster that prohibited your organization from meeting the standard/element. During the accreditation survey, the surveyor will document all findings which will be reviewed by our Review Oversight Committee (ROC) to determine if any accommodations or exceptions should be granted.

The organization should communicate with the assigned ASC if accommodations are requested.

MBHO 2025

8.15.2024 Retroactive Changes to System Controls Standards NCQA posted a memo with changes to the NCQA Accreditation Standards for the 2024 and 2025 Standards Years indicating that organizations are no longer required to describe their process for system controls monitoring or their auditing methodology in their policies and procedures (e.g., UM 12, Element A, factor 7 in HPA is scored NA). Does this mean organizations are no longer required to monitor their UM and CR system controls as required in the oversight elements (e.g., UM 12, Element B in HPA)?

No. Organizations are still required to monitor for system controls. The NA for the system controls policies and procedures requirement (e.g., UM 12, Element A, factor 7, in Health Plan Accreditation) does not affect an organization’s ability to meet the corresponding system controls monitoring requirement (e.g., UM 12, Element B in Health Plan Accreditation); it means the organization is not required to describe the monitoring process in its policies and procedures, but must monitor that its systems are protecting data from unauthorized modifications. Also, as noted in “Related information” in the monitoring requirements (e.g., UM 12, Element B in Health Plan Accreditation), NCQA only reviews specific components for monitoring (e.g., for UM, NCQA reviews that the organization monitored receipt and notification dates).

Note: The referenced memo is on the NCQA website at https://www.ncqa.org/wp-content/uploads/2025-Retroactive-Changes-Memo_Final.pdf. It applies to the 2024/2025 standards year only; no exceptions (NA scores or other changes) will be made for the 2023 or prior standards years. Surveys conducted on standards prior to 2024 standards will be reviewed and scored accordingly; any corrective actions issued prior to the 2024 standards still apply

MBHO 2024

5.15.2024 Use of AI for UM Decisions May organizations use artificial intelligence to make medical necessity denial decisions or appeal decisions?

No. NCQA UM standards do not allow the use of AI to make medical necessity denial decisions, or any appeal decisions.

If an organization uses AI in the UM process, medical necessity review requires that denial decisions be made only by an appropriate clinical professional and appeal decisions require same-or-similar specialist review, as specified in the NCQA standards. 

MBHO 2024

3.15.2024 New Consensus-Based Entity for Performance Measurement Since the National Quality Forum (NQF) is no longer the consensus-based entity for CMS, what source can we use to identify standardized measures?

Battelle replaced NQF as the consensus-based entity for CMS; the Battelle Partnership for Quality Measurement (PQM) Submission Tool and Repository Measure Database can be found here: https://p4qm.org/. Organizations may only use measures classified as “Endorsed."

MBHO 2013

11.15.2023 Notice of Medicare Non-Coverage (NOMNC) Denials For the UM file review universe, should plans include concurrent denials for Medicare members that involve issuance of a Notice of Medicare Non-Coverage (NOMNC) document?

No. Notice of Medicare Non-Coverage (NOMNC) denial files are out of NCQA’s scope of review and should be excluded from the UM file universe.

MBHO 2024

11.15.2023 Using SAM.gov for Medicare/Medicaid Sanctions Is SAM.gov an acceptable source for verifying Medicare and Medicaid sanctions?

Yes. Organizations may use SAM.gov to verify Medicare and Medicaid sanctions for CR 3, Element B, factor 2 and CR 5, Element A, factor 1.

MBHO 2024

10.16.2023 Credentialing application question about present illegal drug use Would the following question on a credentialing application meet the intent of CR 3, Element C, factor 2? “Are you currently using illegal drugs that could affect your ability to practice medicine?”

Yes. NCQA uses language in the Explanation that organizations may use more general or extensive language to query practitioners about impairment.

Note: This question was previously posted on August 15, 2023 and reevaluated by NCQA. This FAQ answer replaces the previously posted response.

MBHO 2024

10.16.2023 CAQH Application: Illegal drug use question Does the CAQH application question about lack of current illegal drug use meet the intent of NCQA’s requirement in CR 3, Element C, factor 2?

Yes, the following CAQH question meets the intent of the requirement in CR 3, Element C, factor 2:

“Are you currently engaged in the illegal use of drugs?* ("Currently" means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.)"

CAQH provides additional information regarding what "currently" means that aligns with language in the explanation of CR 3, Element C, factor 2 that the organization may use more general or extensive language to query practitioners about impairment.

MBHO 2024

10.16.2023 External organizations providing print services only Does NCQA consider it delegation if an organization contracts with an external organization that provides print services only and does not provide mail services?

No. An organization that only provides print services is not considered a delegate or a vendor, and is outside the scope of NCQA requirements.

MBHO 2024

10.16.2023 UM 12, Element C, factor 2 for mail service delegates Can organizations submit a mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit for UM 12, Element C, factor 2?

Yes. Organizations may submit the mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit. This is not required to be specified in the delegation agreement.

MBHO 2023