FAQ Directory

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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1.09.2023 January 2023 Summary of Updates What changes were made to the PCMH Standards and Guidelines for Version 8.1?

TopicUpdate Highlights
Front MatterAdded definitions of “electronic health record (EHR)” and “certified electronic health record technology (CEHRT).”
TC 05Added a note that beginning in 2024, practices will be required to have an EHR.
KM 09Added a note that gender identify and sexual orientation requirements apply to all patients 18 years of age and older.
CM 10Replaced “person-driven outcomes approach” with “person-centered outcomes approach.”
QI 08 & QI 09PCMH QI 08 and QI 09: Added notes stating that if the measures reported in QI 01 or QI 02 do not leave room for improvement, practices may choose different measures within the categories to focus improvement efforts on. 

PCMH 2017

12.27.2022 Annual Reporting Why are evaluators asking for the practice to provide an explanation for performance rates? What should the explanation consist of?

Evaluators may ask practices to provide an explanation, or context and reasoning, for the data submitted. If a reported performance rate seems too low (or too high), the evaluator may ask the practice to enter an explanation of the performance in the Notes section of QPASS.  

Practices are expected to provide a clear and succinct response as to why their performance rate is low, or unusually high. Because practices are expected to have fully implemented PMCH workflows and processes, the Review Oversight Committee (ROC) members would like to understand the reasoning behind the reported performance rates.  

PCMH 2017

7.05.2022 KM 09 For which patients does a PCMH need to collect sexual orientation and gender identity data?

Starting in 2023 for Transforming practices and in 2024 for currently recognized practices, direct collection of data on sexual orientation and gender identity of patients is required for KM 09. This requirement applies to all patients aged 18+, though practices are encouraged to also ask adolescent patients if they have a system for doing so.

PCMH 2017

6.30.2022 July 2022 Summary of Updates What changes were made to the PCMH Standards and Guidelines for Version 8?

TopicUpdate Highlights
Policies and ProceduresSection restructured
Policies and ProceduresAddition of language regarding Corrective Action Plans
KM 09Addition of Sexual Orientation and Gender Identity as required topics of data collection. Added requirement that data be direct collection
KM 10Added requirement that data be direct collection
CM 10New elective criterion regarding person-driven outcomes
Appendix 2 – GlossaryAdded “Age as a Vulnerability”

PCMH 2017

6.13.2022 AR CC 4 For AR CC 4: Referral Tracking (aligns with PCMH CC 11), must practices meet a percentage threshold to meet criteria? (PCMH AR 2022)

No. There is no percentage threshold for referral tracking measures. The expectation is that practices track important referrals routinely; if performance is lower than expected, the practice should enter the rationale for their low percentage in the Notes from the Organization section in QPASS.

For example, if data show a 30% return rate, that means 70% of the practice’s referred patients never had a report returned to their PCP. 

PCMH 2017

6.13.2022 For AR-KM 1: Medication Lists (aligns with PCMH KM 15), is a reported rate <80% automatically marked as “Not Met”? For AR-KM 1: Medication Lists (aligns with PCMH KM 15), is a reported rate <80% automatically marked as “Not Met”? (PCMH AR 2022)

Yes. AR-KM 1 confirms that practices meet PCMH KM 15, in which more than 80% compliance is required for medication lists. A rate less than or equal to 80% does not meet criteria.

PCMH 2017

4.01.2022 Is there a minimum threshold requirement when reporting a rate for Annual Reporting?

It depends. If the AR requirement aligns with a PCMH criteria that specifies a threshold, then that value would be the minimum threshold. However, if a threshold is not explicitly stated in the criteria, then a threshold of 80% or more is expected to ensure consistent application of the process. Please note that there may be some cases where it’s acceptable for the rate to fall below 80%. 
An explanation is required for practices that report a rate less than 80% for the following criteria: AR-AC 1, AR-AC 2, AR-CC 3 [Tracking Imaging Results], and AR-CC 3 [Tracking Lab Results]. 
Additionally, this threshold requirement of 80% would also apply if a practice chooses to submit a depression screening measure for AR-QI 1.

PCMH 2017

4.01.2022 Why do I need to provide more information for a low denominator or rate if there is no minimum requirement?

It is to ensure patient safety and routine implementation of medical home activities. Depending on the population served and/or the reporting period, a small denominator is unexpected and may indicate issues (e.g., with data, documentation, implementation). Providing additional information allows the practice to explain—beyond the numbers—when performance is outside the expected range.

PCMH 2017

4.01.2022 Is there a minimum denominator requirement when reporting a rate for Annual Reporting?

No. There is no minimum denominator requirement. A sample of 30 (or more, because this increases the reliability of the sample) is expected to ensure statistical soundness, but there may be cases where it may be appropriate for the denominator to be <30. NCQA requests practices enter an explanation in the Notes from the Organization section in QPASS in this case.

If a practice reports a denominator <30 without a note, the evaluator may contact the practice to confirm data accuracy and to understand the data. The evaluation will be returned to the practice so they can enter an explanation in the Notes from the Organization section for the cited criteria.

PCMH 2017

6.29.2021 July 2021 Summary of Updates What changes were made to the PCMH Standards and Guidelines in Version 7?

TopicUpdate Highlights
Policies and ProceduresAdded a section on Natural Disasters and Cybercrime.
Policies and ProceduresUpdated policy on eligibility to clarify that organizations that operate entirely remotely are eligible.
Appendix 2 – GlossaryAdded an entry on Behavioral Health Care Clinician.
TC 08/BH 01Added a note to the guidance language to clarify the required qualifications of a Behavioral Health Care Manager.
KM 20/BH 13Updated the list of CDS examples in the guidance language.
AC 04Added language to the guidance to clarify that patient inquiries regarding prescription refills or appointment requests are not considered clinical advice.
CM 06Updated guidance language to detail how Person-Driven Outcome goals can be used to meet the criteria.
QI 01/ QI 02Measures data must be input from the new ‘Measures Reporting’ tile of the Organization Dashboard.
Appendix 5Redesigned Appendix 5 to outline measures reporting including a table of standardized measures now supported.
Distinction in Behavioral Health IntegrationClarified that already Recognized practices seeking Distinction have one virtual review.

PCMH 2017

6.25.2020 July 2020 PCMH Summary of Changes What changes were made to the PCMH Standards and Guidelines?

PCMH (Version 6) Summary of Changes
TopicUpdate Highlights
Standards and Guidelines / Appendix 7The New York State PCMH program was integrated into the PCMH Standards and Guidelines and is no longer a separate publication. The ‘NYS’ icon was added to all 12 required criteria for NYS PCMH. The new Appendix 7,  NYS PCMH Recognition Program, outlines the specifics of the NYS program.
Standards and GuidelinesAdded the ‘Site-Specific’ and ‘Cross-Program Shared Credit Option’ symbols to all relevant criteria.
Standards and Guidelines/ Appendix 6The new appendix outlines the updated Merger, Acquisition and Consolidation Policy for Recognition Programs policy.
TC 03Updated language describing an appropriate external PCMH collaborative and clarified than participation in an HIE will not meet the requirement.
TC 08Highlighted the behavioral healthcare manager may conduct their duties through telehealth.
TC 09Specified that if appointments are conducted using telehealth, the practice should have a process for informing patients about the availability.
KM 04Clarified that the practice must use a standardized screening tool and have a process for following up on results.
KM 05Clarified that asking patients for the date of their last dental exam or providing a list of local dentists does not meet the intent of the criterion.
KM 09Specified that age and gender are not acceptable as a third aspect of diversity.
KM 11ASpecified that the identification of a disparity in care/service for a vulnerable group should be driven by the practice’s data and compared to the general practice population. Actions taken to reduce the disparity should be specific to that vulnerable group.
KM 13Specified that excellence in a performance-based recognition programs must be at the site level.
AC 01Specified that AC 01 focuses on assessing patient access needs and preferences specific to appointments. Also clarified that this differs from more general patient experience assessment of access in QI 04.
AC 02-AC 03Highlighted that same-day appointments and after-hours appointments may be conducted through telehealth.
AC 03Clarified that an ED cannot be used to provide appointments outside business hours.
AC 04 and AC 08Clarified that the report includes calls or messages received both during and after office hours.
AC 05Specified that clinical advice documentation is inclusive of telehealth appointments.
AC 06Clarified that disease specific appointments, home visits and group visits do not meet the intent of the criterion.
AC 12Stated that continuity of the medical record is inclusive of telehealth appointments.
CM 02Specified that small sites and satellite sites may share a care management population with NCQA approval.
CM 03Specified that comprehensive risk stratification must include at least 3 of the categories outlined in CM 01.
CM 04 – CM 08Specified that care plans must be established for at least 75% of patients identified for care management.
CC 09Clarified that the agreement may be with a contracted behavioral telehealth provider.
CC 10Clarified that behavioral health integration may be done through behavioral telehealth.
CC 13

Clarified and updated the expectations for engagement regarding cost implications of treatments options. Practices should not only engage with patients regarding cost implications of treatment options, but also provide information about current coverage and make connections to financial resources as needed.

CC 16Highlighted that follow-up visits may be conducted through telehealth.
CC 21Clarified that electronically exchanging information should include data both sent and received.
QI 04BClarified that the report provided should summarize collected feedback.
QI 05Updated the vulnerable patient population definition.
QI 01 and QI 02Clarified that measures include activities conducted during telehealth visits.
QI 03Specified that major appointments may be conducted in person or via telehealth.
QI 04Clarified that the access category may include questions regarding telehealth.
Policies and ProceduresAdded a description of telehealth in NCQA recognition programs.
Policies and ProceduresUpdated the reconsideration process.
Policies and ProceduresThe “Discretionary Audit” is now called the “Discretionary Review”.
 

PCMH 2017

4.07.2020 TC 04 & QI 17 Can a large organization meet TC 04 and QI 17 through a shared Patient and Family Advisory Council (PFAC)?

Organizations may share a Patient and Family Advisory Council (PFAC) among sites as long as every site has representation on the council. Large organizations with many sites may consider creating multiple PFACs based on region or clinic type.

PCMH 2017