FAQ Directory

PCMH 2017

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

• 5 percent or 50 files, whichever is less, to ensure that information is verified appropriately.
  • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample.

• The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

CVO 2022

Both the organization and delegate must monitor the delegate’s system security controls as part of the delegation oversight requirements and may choose audit as the monitoring method. If auditing is the chosen method, the delegate provides an audit report of modifications that did not comply with its policies and procedures or with the delegation agreement.

The organization is not required to conduct an audit if it determines that the delegate adequately monitored and reported noncompliant modifications, but must provide documentation (a report, meeting minutes or other evidence) that it reviewed and agreed with the delegate’s findings. If the organization determines that the delegate did not adequately monitor noncompliant modifications, it must conduct its own audit of the delegate’s system controls.

The organization must submit its documentation and the delegate’s documentation as part of the survey.  

CVO 2022

No. If the organization provides evidence of advanced system controls capabilities, it must submit policies and procedures for CVO 3, Element B. Policies and procedures must address all factors regarding advanced system control capabilities.
 

CVO 2022

New delegation agreements implemented on or after July 1, 2022, must include a description of the delegate’s CR system security controls.  

For delegation agreements in place prior to July 1, 2022, NCQA has extended the time frame for including a description of CR system controls in the delegation agreement. All delegation agreements under the 2024 CVO standards (effective July 1, 2024) must include a description of CR system controls. Prior to July 1, 2024, organizations may alternatively provide a delegation agreement and other mutually agreed upon documentation OR the delegate's system controls policies and procedures in lieu of a delegation agreement with a description of CR System controls.

CVO 2022

Yes, if the language specifies that the delegate must meet NCQA requirements (CVO 3, Element B, factor 4; CVO 15, Element C, factor 5), template language may be used in the delegation agreement. Language specific to each delegate is not required.
 

CVO 2022

For CVO 3, Element B:

• Factor 1 applies to verification source information from credentialing and recredentialing cycles, covered in CVO 4-12.
• Factor 2 applies to modified credentialing verification information from initial credentialing and recredentialing cycles, covered in CVO 4-12.
• Factors 3–5 apply to all information associated with credentialing/recredentialing of practitioners, covered in CVO 4-14.
• Factor 6 requires a monitoring process that covers compliance with all policies and procedures described in factors 1–5.

CVO 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

Practices should submit an explanation when their performance falls below 80% for the following AR criteria:
•    AR-AC 1: Timely Clinical Advice by Telephone
•    AR-CC 4 (Option): Diagnostic Test Tracking (2 rates)

Practices should submit an explanation when their performance falls below 30% for the following AR criteria:
•    AR-CC 5: Secondary Referral Tracking

If the practice does not submit an explanation, NCQA will contact the practice and request context for their performance rates.

PCSP 2019

It depends. If the AR requirement aligns with a PCSP criteria that explicitly specifies a threshold, then that value would be the minimum threshold. However, if a threshold is not explicitly stated in the criteria, then 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 in the Note section of Q-PASS is required for practices that report a rate less than 80% for the following criteria: AR-AC 01 [Timely Clinical Advice by Telephone], AR-CC 04 [Tracking Lab Test Results], and AR-CC 05 [Tracking Imaging Test Results].

PCSP 2019

NCQA recommends using the previous calendar year (January 1–December 31) when possible. If there is not a calendar year of data, the practice may submit the reporting period it uses to regularly monitor performance.  
 

PCSP 2019

No. There is no percentage threshold for diagnostic test tracking measures. The expectation is that practices track all diagnostic tests 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 ordered tests never had a report returned to their PCP. 
 

PCSP 2019