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Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can  ask a question through My NCQA.

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2.18.2025 Practitioner credentialing application look-back period for the new practitioner race, ethnicity and language requirement Does NCQA expect organizations to include factor 6 in the application prior to July 1, 2025?

Applications processed before July 1, 2025, will not be held to the factor 6 requirement and will be scored NA.

Applications processed on or after July 1, 2025, will be scored on the factor 6 requirement, but will not be held against the 6-month look-back period until surveys on or after January 1, 2026.

Note: CAQH is updating its credentialing application to include fields for race, ethnicity and language, and a statement regarding anti-discrimination. Updates are scheduled to go live on July 1, 2025.

This applies to:
HPA: CR 3, Element C, factor 6.
CRPN: CRA 3, Element A, factor 6; CRC 10, Element A, factor 6; CRC 11, Element A, factor 6.
MBHO: CR 3, Element C, factor 6.

HP 2025

2.18.2025 Medicaid Sanction Look-back Period The 2025 credentialing standards for Ongoing Monitoring and Interventions (e.g., CR 5, Element A, factor 1 in 2025 HPA) require organizations to obtain sanction information from both the state Medicaid agency and one of the additional listed sources. Will the look-back period be adjusted?

No. NCQA will not adjust the look-back period. For verifications conducted before July 1, 2025, the organization or its delegate(s) can obtain information from any source in the factor requirement. Verifications conducted on or after July 1, 2025, must include the state Medicaid agency and one of the other listed sources.

This applies to:
CRPN: CRA 4, Element B, factor 2; CRC 12, Element B, factor 1.
MBHO: CR 5, Element A, factor 1.

HP 2025

2.18.2025 Cervical Cancer Screening (CCS/CCS-E) Continuous Enrollment Criteria What are the correct continuous enrollment criteria for the CCS/CCS-E measures for Quality Rating System (QRS) MY 2024 reporting?

The changes made to the CCS/CCS-E continuous enrollment criteria for QRS MY 2024 was made in error. Use the following continuous enrollment criteria for MY 2024, which align with previous measurement years: 

CCS:

Continuous enrollment: The measurement year.

CCS-E:

The member was enrolled with a medical benefit throughout the participation period.

NCQA certified organizations were tested using the accurate continuous enrollment criteria.

Exchange 2024

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.

HP 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.

HP 2025

1.15.2025 Privacy Protections for Data Is access to physical and cloud servers in the scope of the Privacy Protections of Data requirement?

Yes. The intent of LTSS 2, Element B in CM-LTSS (HE 2, Element F in HEA; LTSS 1, Element E in HPA) is that organizations have policies and procedures in place for managing access to and use of race/ethnicity and language data that cover all forms of media, devices and data storage.

CM-LTSS 2025

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. 

 

HP 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

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 Reviewer Names on Denial and Appeal Notifications (MBHO & UM) Does NCQA require names or signatures of the reviewers on UM denial and appeal notifications?

No. NCQA does not require names or signatures of the reviewers on UM denial and appeal notifications. Please refer to UM 4, Element C and UM 9, Element D for documentation requirements. 

MBHO 2025

1.15.2025 Medication Lists deleted from the Asthma Medication Ration (AMR) measure A new version of the MY 2024 Medication List Directory (MLD) was released on 1/15/2025 with changes to asthma medications. What was the reason for the changes and how does this impact the Asthma Medication Ratio measure specification?

An error was identified in the HEDIS MY 2024 Medication List Directory (released on April 1, 2024). For the Asthma Medication Ratio (AMR) measure, “package size” and “unit” are required to perform calculations. If we cannot find package size and unit for NDC codes, we cannot include the codes in the AMR medication lists. For the MY 2024 Update release of the MLD, an alternative method was used to identify package size and unit so more codes could be included in the medication lists. Because this method resulted in incorrect information, we removed these codes from 11 medication lists.

  • Albuterol Medications
  • Asthma Controller and Reliever Medications
  • Beclomethasone Medications
  • Budesonide Formoterol Medications
  • Budesonide Medications
  • Ciclesonide Medications
  • Fluticasone Medications
  • Fluticasone Salmeterol Medications
  • Formoterol Mometasone Medications
  • Levalbuterol Medications
  • Mometasone Medications

Three medication lists were removed from the AMR measure.

  • Fluticasone Furoate Umeclidinium Vilanterol Medications
  • Salmeterol Medications
  • Tiotropium Medications

Customers who purchased the HEDIS MY 2024 Medication List Directory should re-download the file from the My Downloads section of their My NCQA account. Customers who purchased a product that contains the AMR measure specification should delete the three medication lists, consistent with how changes from the technical update are applied.

HEDIS 2024

1.15.2025 Use of documents produced using the Consolidated Clinical Document Architecture (C-CDA) standard Can documentation produced using the C-CDA standard, such as Continuity of Care Documents (CCD), discharge summaries or progress notes, be used as proof-of-service documentation or medical record review?

No. Documents produced using the C-CDA standard are structured summaries or snapshots of information used to facilitate data exchange. They are not eligible as proof of service for HEDIS MY 2024, and should not be used for medical record review abstraction.  

HEDIS 2024