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FAQ Directory: Managed Behavioral Healthcare Organization Accreditation

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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. 

 

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

1.15.2025 Sources for Medicare Sanctions (MBHO) 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. 

MBHO 2025

1.15.2025 NPDB: Acceptable Source for Medicare and Medicaid Exclusions (MBHO) 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. 

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 Updated: MBHO: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?

Yes. Using UM 12: Delegation of UM as an example, the following describes factors that would be considered NA:

UM 12, Element A: Delegation Agreement

  • Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution
    • Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance.
    • Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
  • Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.

UM 12, Element C: Review of the UM Program

  • Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates
  • Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
    • Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).

Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit. This must be specified in the delegation agreement.

Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.

MBHO 2023

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