FAQ Directory

This applies to the following Programs and Years:

NCQA is retaining the childhood and adolescent immunization measures in HEDIS, and as a factor in NCQA’s Health Plan Ratings.

NCQA is aware of the updates made by the CDC and HHS to the child and adolescent immunization schedule. The 2025 HEDIS measurement data has already been collected according to the HEDIS MY 2025 CIS-E and IMA-E measure specifications. As a result, NCQA is not making any changes to HEDIS MY 2025 measure reporting requirements or to Health Plan Ratings 2026 scoring based on HEDIS MY 2025 data.  

This applies to the following Programs and Years:

Yes. Depending on the data generated for the mammography procedure, one procedure can be included as more than one episode in the initial population. The HEDIS MY 2025 measure specifications for DBM-E and FMA-E do not include steps to deduplicate mammography episodes where a procedure is represented multiple times in available data. For example, a mammography procedure can be represented in multiple claims (e.g., professional and facility claim) or within multiple data types (e.g., claim and clinical encounter). There are no steps in the measure specification to deduplicate across those data. Therefore, organizations reporting the measures can observe that a mammography procedure can be included as more than one episode in the initial population.

Organizations are allowed to deduplicate if there is a mechanism to confirm that the mammography procedures represented in the data represent the same episode. Please note that automated deduplication based on date of service is not appropriate as there may be multiple mammography procedures on the same day.  

The DBM-E and FMA-E measures are newly introduced for HEDIS MY 2025. Organizations that participate in reporting first-year measures are appreciated. Their reported results will not be public. The first-year results are used by NCQA to identify additional measure development needs and confirm the feasibility, reliability and validity of the measures prior to moving them to public reporting status. 

This applies to the following Programs and Years:

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: 

• A description of actions to make UM criteria available electronically at the point of care.
• A timeline for implementation on or before June 30, 2027.

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:

• Health Plan Accreditation: UM 2, Element B.
• Behavioral Health Accreditation: UM 2, Element B.
• UM Accreditation: UM 4, Element B.

This applies to the following Programs and Years:

Yes, if a person in denominator 2 is 12 years of age at the start of the measurement period and received tobacco cessation counseling within the 180 days prior to the measurement period at 11 years of age, this person is compliant for numerator 2.

This clarification will be included in the HEDIS Volume 2 MY 2026 Technical Update, scheduled for release on March 31, 2026.

This applies to the following Programs and Years:

No, pharmacotherapy interventions provided to persons aged 17 years and younger at the time of the dispensing event do not count towards numerator 2 because there are no current FDA-approved tobacco cessation medications for persons under 18 years of age. If a person in denominator 2 is 18 years of age at the start of the measurement period and received pharmacotherapy interventions within the 180 days prior to the measurement period at 17 years of age, this person is not compliant with numerator 2.  

This clarification will be included in the HEDIS Volume 2 MY 2026 Technical Update, scheduled for release on March 31, 2026.

This applies to the following Programs and Years:

No. C-CDA documents cannot be used for these purposes as the documents are electronically generated and not the same as the medical record documented in the primary source system where care was originally recorded (e.g. electronic medical record). This includes C-CDA documents received from HIEs.

HIEs support the exchange of clinical information, an important function for the delivery of care. Organizations are encouraged to use electronic files received from an HIE, such as electronic C-CDA or FHIR documents (e.g., C-CDA XML, FHIR JSON), as a supplemental data source.

This applies to the following Programs and Years:

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:

• Health Plan Accreditation: UM 1, Elements B-E. 
• Behavioral Health Accreditation: UM 1, Elements B-D.
• Utilization Management Accreditation: UM 3, Elements B-E.

This applies to the following Programs and Years:

NCQA currently maintains prior year HPR scores on NCQA’s HPR Final Results website.

You can also purchase the Health Plan Ratings in Excel Format file which lists plan’s overall rating, composite, subcomposite and measure-level scores from the NCQA store. 

This applies to the following Programs and Years:

For AR-KM 3 (2026 Annual Reporting) the threshold will remain at more than 80% with the intent that practices will begin implementing updated workflows to be able to reach more than 90% by Annual Reporting in 2027.

For PCMH, a transition of care is defined as: A patient’s movement from one care setting (e.g., hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another. That said, medication review and reconciliation should occur at transitions of care, or at least annually. If a patient has experienced multiple transitions of care within the reporting period (e.g. hospital discharge, post cardiology visit, hospital discharge, post gastroenterology visit) they should be counted in the denominator for each transition of care.
 

This applies to the following Programs and Years:

NCQA will give organizations credit (an individual measure rating of “5”) if both reported Direct Race and Direct Ethnicity is ≥20%. Organizations that do not report Direct Race and Direct Ethnicity ≥20% will receive an individual measure rating of “0”. The measure has a weight of 1.0. 

This applies to the following Programs and Years:

To calculate individual measure scores, NCQA truncates final raw rates and percentiles to 3 decimals and compares the rates submitted by plans to The National All Lines of Business 10th, 33.33rd, 66.67th and 90th measure benchmarks and percentiles, and then assigns the individual measure rating (calculated as whole numbers on a 1–5 scale) that the plans receive for each measure as follows:

5 = plans with a rate ≥ 90^th percentile (top 10% of plans)

4 = plans in the top third but not in the top decile (66.67^th percentile ≤ rate < 90^th percentile)

3 = the middle one-third of plans or (33.33^rd percentile ≤ rate < 66.67^th percentile)

2 = plans above the bottom 10% of plans but in the bottom one-third of plans (10^th percentile ≤ rate < 33.33^rd percentile)

1 = plans with a rate < 10^th percentile (in the bottom 10% of plans)

This applies to the following Programs and Years: