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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6.23.2023 July 2023 PCSP Summary of Updates What changes were made to the PCSP Standards and Guidelines for Version 6?

Topic Update Highlights
Front Matter (Audit Section) Evidence of implementation submitted for an audit, including reporting data, must be recent to the time of the audit.
Front Matter Added a section addressing conflicts with regulatory requirements. This applies to all Recognition products.
CM 04 Added: “The care plan needs to be written in a health literacy level accessible to the patient (not medical jargon or billing codes).”

Also added – “Note: After-visit summaries may only be used if it contains plain language and shows patient involvement in the creation of the plan.”
KM 06 Removed “pronouns” and added “language” in the guidance section as examples that may not be submitted for “other aspects of health”.
KM 09
 		 Added clarification on evidence: “Practices are to submit a report that is broken down by numerator/denominator and percentages for each category. For example, Black or African American = 400/1000 (40%); Asian = 300/1000 (30%), etc.”
PM 20 New criterion – Person-Driven Outcomes Approach: Monitoring and Follow-Up

This applies to the following Programs and Years:
PCSP 2019

6.15.2023 Use of a Delegate's Self-Service Portal for Delegation Reporting Is it acceptable for organizations to pull reports from a delegate’s system for the delegation agreement reporting requirement?

Yes, if the delegation agreement addresses the required information in the Explanation. The delegation agreement must specify:

  • How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
  • What information is reported by the delegate in the delegate's system about the delegated activities.
  • How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).

This applies to the following Programs and Years:
CVO 2022|CM 2020|CM-LTSS 2020|WHP 2020|PHP 2019|HEA 2023

6.15.2023 Use of Delegate's Self-Service Portal for Delegation Reporting Is it acceptable for organizations to pull reports from a delegate’s system for the delegation agreement reporting requirement?

Yes, if the delegation agreement addresses the required information in the Explanation (e.g., CR 8, Element A, factor 3 for credentialing). The delegation agreement must specify:

  • How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
  • What information is reported by the delegate in the delegate's system about the delegated activities.
  • How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).

This applies to the following Programs and Years:
HP 2023|MBHO 2023|UM-CR-PN 2023

5.15.2023 Colorectal Cancer Screening (COL-E) Should the Colorectal Cancer Screening-E (COL-E) age stratification be updated?

Yes. Replace the reference to “46-49” with “46-50,” and replace the reference to “50-75” with “51-75” in the age stratification and in Table COL-E-A-4: Data Elements for Colorectal Cancer Screening.

This applies to the following Programs and Years:
Exchange MY

5.15.2023 Applicable Standards for Mail Service Organizations Considered Delegates What standards are considered a delegation relationship if an organization uses a mail service organization to meet the distribution requirements?

NCQA considers the following standards to be a delegation relationship if an organization uses a mail service organization to meet the distribution requirements:

  • NET 4, Element A: Notification of Termination
  • NET 4, Element B: Continued Access to Practitioners
  • UM 5, Elements A, B, C: Timeliness of UM Decisions
  • UM 7, Elements B, C, E, F, H, I: Denial Notices
  • UM 9, Elements B, D: Appropriate Handling of Appeals
  • UM 11, Element B: Pharmaceutical Restrictions/Preferences
  • UM 11, Element C: Pharmaceutical Patient Safety Issues

This applies to the following Programs and Years:
HP 2022, 2023|UM-CR-PN 2022, 2023

5.15.2023 MBHO: Applicable Standards for Mail Service Organizations Considered Delegates What standards are considered a delegation relationship if an organization uses a mail service organization to meet the distribution requirements?

NCQA considers the following standards to be a delegation relationship if an organization uses a mail service organization to meet the distribution requirements:

  • CC 3, Element A: Notification of Termination
  • CC 3, Element B: Continued Access to Practitioners
  • UM 5, Element A: Timeliness of UM Decisions
  • UM 7, Elements B, C: Denial Notices
  • UM 9, Elements B, D: Appropriate Handling of Appeals

This applies to the following Programs and Years:
MBHO 2022, 2023

5.15.2023 Social Need Screening and Intervention (SNS-E) Should the SNS-E measure include exclusion criteria for Medicare members?

No. There are no Medicare member exclusions. Remove the second bullet from Exclusion 1, which reads:

  • Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
    • Enrolled in an Institutional SNP (I-SNP) any time during the measurement period.
    • Living long-term in an institution any time during the measurement period, as identified by the LTI flag in the Monthly Membership Detail Data File. Use the run date of the file to determine if a member had an LTI flag during the measurement period.

This applies to the following Programs and Years:
Exchange MY

5.15.2023 Definition of Annual Does NCQA’s definition of “annual” allow for a 2-month grace period?

As noted in the Glossary appendix, NCQA’s long-standing definition of “annual” is 12 months plus a 2-month grace period (12–14 months). “Grace period” refers to allowing organizations to complete an activity after it is due and not before it is due.

This applies to the following Programs and Years:
CVO 2022|CM 2020|CM-LTSS 2020|HP 2023|MBHO 2023|UM-CR-PN 2023|HEA 2023

4.24.2023 Multiple Health Plan Ratings for One Product in a State How is it possible for plans to have multiple ratings for one product within a given state?

Plans can have multiple ratings for one product within the same state because they might have certain state or contractual submission requirements that fall outside of the combined submission requisite that they send to NCQA for Accreditation purposes. Therefore, this results in plans submitting one combined submission (required) for Accreditation and then they still elect to select other submissions for state or other contractual obligations, which NCQA includes as part of its Ratings program.

This applies to the following Programs and Years:

4.24.2023 Electronic Clinical Data Distinction (ECDS) in Health Plan Ratings/Report Cards Where can I find more information regarding the Electronic Clinical Data distinction?

4.24.2023 Health Plan Ratings Information Confirmation Why do I have to confirm this information if our plan is not Accredited, or we will say “No” to Public Reporting?

We need you to confirm your plan details (e.g., Accreditation status, State Coverage, Family Association, Organization ID, Submission ID) because this impacts how you will be listed publicly when we release HPR on or around September 15, regardless of your Accreditation status or Public Reporting decision.

This applies to the following Programs and Years:

4.24.2023 Plan Confirmation Login for Health Plan Ratings Why can’t I log on to Plan Confirmation? Or I can log on, but I don’t see any plans?

Access is controlled by the plan’s Primary HEDIS Contact, who can grant access through the “Manage Users” section of Plan Confirmation. Please contact this individual at your organization to request access.

This applies to the following Programs and Years:
HPR 2022, 2023