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.
Yes. Member-reported biometric values (height, weight, BMI percentile) collected during a telephone visit, e-visit or virtual check-in that meet the requirements of General Guidelines 39: Member-Reported Services and Biometric Values are eligible for use in reporting.
**This FAQ applies to HEDIS Volume 2 MY 2020 & MY 2021.
HEDIS 2021
Yes. Although the required palliative care exclusion is intended to be identified using administrative data, medical record and supplemental data may also be used. If a member is identified as being in palliative care during hybrid medical record review, the member must be removed from the sample and replaced with a member from the oversample. Count the member in the “Number of medical records excluded because of valid data errors” data element.
If organizations use supplemental data to remove members in palliative care from administrative-only measures or hybrid measures, they must follow the supplemental data guidelines (General Guideline 31). Count these members in the “Number of required exclusions” data element.
**This FAQ applies to HEDIS Volume 2 MY 2020 & MY 2021.
HEDIS 2021
NCQA added the word “all” to CR 7 in the 2020 HPA standards and guidelines because it expects organizations to have policies for assessing all providers with which they contract. However, under the 2020 standards and in previous years, NCQA only scores policies for providers listed in CR 7, Elements B and C.
Because the definition may not be sufficient to clearly identify which organizations NCQA considers “providers,” here is a list of provider types in addition to those listed in Elements B and C:
UM-CR-PN 2020
If an organization contracts with external entities to store its own UM data or contracts with UM delegates that store data, NCQA also reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. If factor 6 is not addressed in a contract, the organization may also present the external entity’s policies and procedures for review. NCQA reviews documentation from the organization and from each external entity against the factor. To be scored “yes,” the organization and each external entity’s documentation must meet the factor.
Note: The underlined text is an update to the FAQ posted on June 15, 2020. Refer also to the FAQ on the same date regarding cloud storage entities.
MBHO 2020
If an organization contracts with external entities to store its own UM data or contracts with UM delegates that store data, NCQA also reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. If factor 6 is not addressed in a contract, the organization may also present the external entity’s policies and procedures for review. NCQA reviews documentation from the organization and from each external entity against the factor. To be scored “yes,” the organization's and each external entity’s documentation must meet the factor.
Note: The underlined text is an update to the FAQ posted on June 15, 2020. Refer also to the FAQ on the same date regarding cloud storage entities.
UM-CR-PN 2020
If an organization contracts with external entities to store its own credentialing data or contracts with CR delegates that store data, NCQA also reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. If factor 4 is not addressed in a contract, the organization may also present the external entity’s policies and procedures for review. NCQA reviews documentation from the organization and from each external entity against the factor. To be scored “yes,” the organization's and each external entity’s documentation must meet the factor.
Note: The underlined text is an update to the FAQ posted on June 15, 2020. Refer also to the FAQ on the same date regarding cloud storage entities.
UM-CR-PN 2020
It depends. For initial measurement, the organization conducts quantitative and qualitative analysis of data.
For remeasurement, the organization conducts quantitative analysis and also conducts qualitative analysis if quantitative analysis demonstrates that stated goals were not met.
HP 2020
| PCSP (Version 3) Summary of Changes | |
| Topic | Update Highlights |
| Standards and Guidelines | Added the ‘Shared Credit’ symbol to all relevant criteria. |
| Standards and Guidelines/ Appendix 4 | The new appendix outlines the updated Merger, Acquisition and Consolidation Policy for Recognition Programs policy. |
| TC 03 | Updated language describing an appropriate external patient-centered collaborative activities and clarified than participation in an HIE will not meet the requirement. |
| TC 08 | Specified that if appointments are conducted using telehealth, the practice should have a process for informing patients about the availability. |
| RM 11 | Highlighted that this criterion is particularly relevant to self-referred patients. |
| KM 04 | Specified that monitoring pain or functional health status may not be appropriate for all specialties, so if the category is not relevant or appropriate, a practice should make a different selection. |
| KM 05 | Clarified that the practice must use a standardized screening tool and have a process for following up on results. |
| KM 06 | Specified that age and gender are not acceptable as a third aspect of diversity. |
| KM 15 | Clarified that patients should be proactively reminded of needed services related to the specialty. |
| KM 20 | Specified that excellence in a performance-based recognition programs must be at the site level. |
| AC 01 | Clarified that the focus of the criterion is to ensure that patients have access to the practice for urgent needs. |
| AC 02 and AC 03 | Stated that the reports include calls or messages received both during and after office hours. |
| AC 04 | Specified that clinical advice documentation is inclusive of telehealth appointments. |
| AC 05 | Stated that continuity of the medical record is inclusive of telehealth appointments. |
| PM 01 and PM 11 | Clarified the guidance in PM 01 by moving the reference to motivational interviewing and treatment goals to PM 11. |
| CC 09 | Highlighted that follow-up visits may be conducted through telehealth and that follow-up should be consistently documented. |
| CC 13 | Clarified that electronically exchanging information should include data both sent and received. |
| QI 01F | Clarified that the report provided should summarize collected feedback. |
| QI 01 | Clarified that measures include activities conducted during telehealth visits. |
| QI 01D. | Specified that major appointments may be conducted in person or via telehealth. |
| QI 01E. | Clarified that the access category may include questions regarding telehealth. |
| QI 05 | Updated the vulnerable patient population definition. |
| Policies and Procedures | Added a description of telehealth in NCQA recognition programs. |
| Policies and Procedures | Updated the reconsideration process. |
| Policies and Procedures | Doctoral or master's level certified or licensed chemical dependency counselors have been added as eligible clinicians to the program. |
| Policies and Procedures | The “Discretionary Audit” is now called the “Discretionary Review”. |
PCSP 2019
| PCMH (Version 6) Summary of Changes | |
| Topic | Update Highlights |
| Standards and Guidelines / Appendix 7 | The 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 Guidelines | Added the ‘Site-Specific’ and ‘Cross-Program Shared Credit Option’ symbols to all relevant criteria. |
| Standards and Guidelines/ Appendix 6 | The new appendix outlines the updated Merger, Acquisition and Consolidation Policy for Recognition Programs policy. |
| TC 03 | Updated language describing an appropriate external PCMH collaborative and clarified than participation in an HIE will not meet the requirement. |
| TC 08 | Highlighted the behavioral healthcare manager may conduct their duties through telehealth. |
| TC 09 | Specified that if appointments are conducted using telehealth, the practice should have a process for informing patients about the availability. |
| KM 04 | Clarified that the practice must use a standardized screening tool and have a process for following up on results. |
| KM 05 | Clarified 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 09 | Specified that age and gender are not acceptable as a third aspect of diversity. |
| KM 11A | Specified 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 13 | Specified that excellence in a performance-based recognition programs must be at the site level. |
| AC 01 | Specified 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 03 | Highlighted that same-day appointments and after-hours appointments may be conducted through telehealth. |
| AC 03 | Clarified that an ED cannot be used to provide appointments outside business hours. |
| AC 04 and AC 08 | Clarified that the report includes calls or messages received both during and after office hours. |
| AC 05 | Specified that clinical advice documentation is inclusive of telehealth appointments. |
| AC 06 | Clarified that disease specific appointments, home visits and group visits do not meet the intent of the criterion. |
| AC 12 | Stated that continuity of the medical record is inclusive of telehealth appointments. |
| CM 02 | Specified that small sites and satellite sites may share a care management population with NCQA approval. |
| CM 03 | Specified that comprehensive risk stratification must include at least 3 of the categories outlined in CM 01. |
| CM 04 – CM 08 | Specified that care plans must be established for at least 75% of patients identified for care management. |
| CC 09 | Clarified that the agreement may be with a contracted behavioral telehealth provider. |
| CC 10 | Clarified 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 16 | Highlighted that follow-up visits may be conducted through telehealth. |
| CC 21 | Clarified that electronically exchanging information should include data both sent and received. |
| QI 04B | Clarified that the report provided should summarize collected feedback. |
| QI 05 | Updated the vulnerable patient population definition. |
| QI 01 and QI 02 | Clarified that measures include activities conducted during telehealth visits. |
| QI 03 | Specified that major appointments may be conducted in person or via telehealth. |
| QI 04 | Clarified that the access category may include questions regarding telehealth. |
| Policies and Procedures | Added a description of telehealth in NCQA recognition programs. |
| Policies and Procedures | Updated the reconsideration process. |
| Policies and Procedures | The “Discretionary Audit” is now called the “Discretionary Review”. |
PCMH 2017
Yes. Distributing the rights and responsibilities statement to all members and practitioners (new upon enrollment and annually to existing) is acceptable, because it is consistent with prior years' and exceeds the standards effective July 1, 2020. Factors 2 and 4 will be scored yes; organizations are not required to track requests for existing members and practitioners during the look-back period.
MBHO 2020
NCQA includes external entities that store, create, modify or use UM data for any function covered by the UM standards on behalf of the organization in the scope of Elements A and B, factor 6, with the exception of organizations whose only UM service provided for the organization is to provide cloud-based data storage functions and not services that create, modify or use UM data.
UM-CR-PN 2020
