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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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1.15.2025 Privacy Protections for Data Is access to physical and cloud servers in the scope of the Privacy Protections of Data requirement?

Yes. The intent of LTSS 2, Element B in CM-LTSS (HE 2, Element F in HEA; LTSS 1, Element E in HPA) is that organizations have policies and procedures in place for managing access to and use of race/ethnicity and language data that cover all forms of media, devices and data storage.

CM-LTSS 2025

1.15.2025 Define “processed” related to credentialing files Under the verification time limits, NCQA added a note that states the new verification time limits apply to files processed by the organization or its delegate(s) on or after July 1, 2025. Files processed before July 1, 2025, are scored against the previous verification time limits. What does “processed” mean for Health Plan and Credentialing Accreditation and Credentialing Certification?

For Health Plan, MBHO and Credentialing Accreditation, “processed” refers to the credentialing decision date. 

For Credentialing Certification, “processed” refers to the date when credentialing verifications are reported to the client. 

 

HP 2025

1.15.2025 NPDB: Acceptable Source for Medicare and Medicaid Exclusions (MBHO) Is the NPDB an acceptable source for Medicare and Medicaid exclusions?

Yes. The NPDB is an acceptable source for both Medicare and Medicaid exclusions.  

For Medicaid, organizations must obtain exclusion information from the state Medicaid agency, in addition to either of the following sources: 

  • NPDB, or 

  • List of Excluded Individuals and Entities maintained by OIG and available over the internet). 

For Medicare, organizations may obtain exclusion information from any of the NCQA acceptable sources. 

MBHO 2025

1.15.2025 Sources for Medicare Sanctions (MBHO) Are organizations required to verify Medicare sanctions from all of the following sources?
• AMA Physician Master File.
• FSMB.
• NPDB.
• SAM.gov.

No. The requirement is that organizations verify Medicare sanctions from any of those sources, but there is no requirement to verify sanctions from all of them. 

MBHO 2025

1.15.2025 Reviewer Names on Denial and Appeal Notifications (MBHO & UM) Does NCQA require names or signatures of the reviewers on UM denial and appeal notifications?

No. NCQA does not require names or signatures of the reviewers on UM denial and appeal notifications. Please refer to UM 4, Element C and UM 9, Element D for documentation requirements. 

MBHO 2025

1.15.2025 Medication Lists deleted from the Asthma Medication Ration (AMR) measure A new version of the MY 2024 Medication List Directory (MLD) was released on 1/15/2025 with changes to asthma medications. What was the reason for the changes and how does this impact the Asthma Medication Ratio measure specification?

An error was identified in the HEDIS MY 2024 Medication List Directory (released on April 1, 2024). For the Asthma Medication Ratio (AMR) measure, “package size” and “unit” are required to perform calculations. If we cannot find package size and unit for NDC codes, we cannot include the codes in the AMR medication lists. For the MY 2024 Update release of the MLD, an alternative method was used to identify package size and unit so more codes could be included in the medication lists. Because this method resulted in incorrect information, we removed these codes from 11 medication lists.

  • Albuterol Medications
  • Asthma Controller and Reliever Medications
  • Beclomethasone Medications
  • Budesonide Formoterol Medications
  • Budesonide Medications
  • Ciclesonide Medications
  • Fluticasone Medications
  • Fluticasone Salmeterol Medications
  • Formoterol Mometasone Medications
  • Levalbuterol Medications
  • Mometasone Medications

Three medication lists were removed from the AMR measure.

  • Fluticasone Furoate Umeclidinium Vilanterol Medications
  • Salmeterol Medications
  • Tiotropium Medications

Customers who purchased the HEDIS MY 2024 Medication List Directory should re-download the file from the My Downloads section of their My NCQA account. Customers who purchased a product that contains the AMR measure specification should delete the three medication lists, consistent with how changes from the technical update are applied.

HEDIS 2024

1.15.2025 Use of documents produced using the Consolidated Clinical Document Architecture (C-CDA) standard Can documentation produced using the C-CDA standard, such as Continuity of Care Documents (CCD), discharge summaries or progress notes, be used as proof-of-service documentation or medical record review?

No. Documents produced using the C-CDA standard are structured summaries or snapshots of information used to facilitate data exchange. They are not eligible as proof of service for HEDIS MY 2024, and should not be used for medical record review abstraction.  

HEDIS 2024

12.16.2024 Sources for Medicare Sanctions Are organizations required to verify Medicare sanctions from all of the following sources?
• AMA Physician Master File.
• FSMB.
• NPDB.
• SAM.gov.

No. The requirement is that organizations verify Medicare sanctions from any of those sources, but there is no requirement to verify sanctions from all of them. 

HP 2025

12.16.2024 NPDB Acceptable Source for Medicare and Medicaid Exclusions Is the NPDB an acceptable source for Medicare and Medicaid exclusions?

Yes. The NPDB is an acceptable source for both Medicare and Medicaid exclusions.

For Medicaid, organizations must obtain exclusion information from the state Medicaid agency, in addition to either of the following sources:

  • NPDB, or
  • List of Excluded Individuals and Entities maintained by OIG and available over the internet).

For Medicare, organizations may obtain exclusion information from any of the NCQA acceptable sources.

HP 2025

12.16.2024 MMP Plans CMS intends to dissolve Medicare-Medicaid Plan (MMP) contracts in 2026. Will that change product line rules for Accreditation?

No. Plans that are responsible for both the Medicare and Medicaid components for dual-eligible members may select Medicare, Medicaid, or both, for Accreditation purposes. 

HP 2025

12.16.2024 Reviewer Names on Denial and Appeal Notifications Does NCQA require names or signatures of the reviewers on UM denial and appeal notifications?

No. NCQA does not require names or signatures of the reviewers on UM denial and appeal notifications. Please refer to UM 4, Element C and UM 9, Element D for documentation requirements.

HP 2025

12.13.2024 Advance Notice of RAND Table Changes for HEDIS MY 2025 How is NCQA changing the release of RAND numbers for HEDIS reporting beginning in MY 2025?

NCQA will remove the RAND table from the Guidelines for Calculations and Sampling with the release of the HEDIS MY 2025 Technical Update on March 31, 2025. Future releases of the HEDIS Volume 2: Technical Specifications for Health Plans publication will not contain a RAND table.

Beginning MY 2025, NCQA will use an alternative timeline and approach to distribute RAND numbers for HEDIS reporting. This information will be released in the NCQA store for purchasers of HEDIS Volume 2 in the November before production of systematic samples for hybrid reporting (e.g., November 2025, for MY 2025).  

Organizations participating in NCQA’s Measure Certification program will receive separate guidance on how NCQA will accommodate this change for certification of systematic sampling logic.

HEDIS 2025