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.
Save your favorite pages and receive notifications whenever they’re updated.
You will be prompted to log in to your NCQA account.
Save your favorite pages and receive notifications whenever they’re updated.
You will be prompted to log in to your NCQA account.
Share this page with a friend or colleague by Email.
We do not share your information with third parties.
Share this page with a friend or colleague by Email.
We do not share your information with third parties.
Print this page.
Print this page.
Organizations may not use PCS responses that are over 3 years old. Questions that relate directly to a measure specification or general guideline that was revised from a previous measurement year should be resubmitted rather than using the previous answer in PCS.
In response to customer feedback, we are retracting the Policy Update issued on July 28, 2025.
Organizations must review sanctions, exclusions, limitations and expiration information at least monthly (once per month), or within 30 calendar days of receiving a new alert, if subscribed to a monitoring service. For example, an organization might conduct a review on September 1, and conduct another on October 15, 2026.
This update applies to applicable products for both the 2025 and 2026 standard years. NCQA will accept processes that follow a monthly schedule or a 30-day interval.
We appreciate your ongoing feedback and support.
Applicable Standards:
HPA: CR 5, Element A, factors 1-3.
MBHO: CR 5, Element A, factors 1-3.
CRPN: CRA 5, Element A, factor 3; CRC 12, Element C, factors 1-3.
Under the 2025 standards and beyond, organizations must monitor adverse events for all practitioners. Limiting monitoring to primary care practitioners and high-volume behavioral healthcare practitioners is no longer acceptable.
This is a change from the 2024 standards.
Applicable Standards:
HPA: CR 5, Element A, factor 5.
MBHO: CR 5, Element A, factor 5.
CRPN: CRA 5, Element A, factor 5.
Although the “Prior Decision Date” field appears to be required, it does not apply to Credentialing Certification file reviews. For now, users should enter the same date used in the “Date Reported” (the date reported to the client) field. This is a temporary fix due to system limitations, and the field is expected to be removed by the end of 2025. Until then, using the same date ensures files can be completed successfully.
Yes, multiple goals can be assigned the same priority level (e.g., “high”), but the organization must still clarify the relative importance of each goal within the same assigned level. The intent of prioritization is to show how goals compare to one another in terms of urgency or importance.
For example, if three goals are all marked “high,” the organization must indicate which of those is the highest priority, second highest, and so on.
Update Notice:
This FAQ is being updated to clarify implementation expectations.
Organizations will have 90 days to implement the guidance outlined in this FAQ.
This means that organizations must adhere to the updated FAQ for surveys conducted on or after January 1, 2026.
Prior to January 1, 2026, organizations may continue to prioritize goals and reporting frequencies as they have in the past.
Applicable Standards:
HPA: PHM 5, Element E
MBHO: QI 8, Element I
CM: CM 4, Element B
CM-LTSS: LTSS 3, Element C
Yes. When an organization conducts its UM Information Integrity audit, the audit universe includes data from the most recent 12 months from the timing of the audit. So, although the audit occurs within the look-back period, data reviewed may include decision notification files from outside the formal look-back window, depending on timing.
Unless a regular operational employee of the organization, a consultant is not to assume responsibility for generating or demonstrating the evidence for Recognition. While external consultants are welcome to be part of the virtual reviews or audit, these calls are led by the appropriate practice team members. NCQA reserves the right to obtain contact information of consultants working with the practice as well as verify the identity of individuals present during the virtual review or audit.
Every qualifying clinician at a practice site is required to be listed in Q-PASS. Clinicians who meet the following three criteria must be listed for each Recognized PCMH site they practice at:
Yes. Applicable clinical staff must be licensed and verified in all states where they provide care to members.
A licensure compact arrangement between states is acceptable if the clinician’s licensure was primary source verified in the clinician’s home state. NCQA reviews the compact agreement for evidence that the state (or states) accepts the home state’s license in lieu of state licensure.
It is up to the organization to ensure that multiple mammograph episodes are the same event if they occur on the same date of service. HEDIS measure certification assumes events on the same day are different mammograms. If evidence shows the mammography episodes are the same, count only one. Organizations should develop their own methods and apply them consistently when reporting.
