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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The expectation is that these facets of the care plan should be happening routinely. NCQA has not set a specific threshold, however if the practice is reporting less than 75% the evaluator may question whether the practice has truly implemented the criteria as part of their care plan routine.
A practice with integrated behavioral health may provide its documented process and evidence of implementation. For evidence of implementation, the practice might demonstrate the practice's internal process for entering patient treatment notes, referral guidance and medication management within its system and how the integrated BH provider updates the PCP about the patient's progress. The documented process may also include how the practice facilitates transition to BH, such as through warm handoffs.
Elective criterion KM 07 goes beyond providing the percentage of patients with social determinants of health documented in the medical record; the report should include the breakdown by social determinant(s) so the practice understands which social determinants impact their patients to better implement appropriate care interventions. The intent of elective criterion is for the practice to show how it monitors social determinants of health at the population level for its patient population and also how it uses that data to address and assist in overcoming those social determinants of health. Reports may be generated from data collected in KM 02 G.
In BH 15 (Core), the practice monitors either a mental health condition OR a substance use disorder. BH 16 is elective because it raises the bar by evaluating whether practices monitor both a mental health condition AND a substance use disorder.
No, the redesigned PCMH process enables practices to enroll and transform into a PCMH over the course of a 12 month period. If the documented process has been implemented for a sufficient amount of time for the practice to demonstrate the needed evidence to meet criteria, the practice may submit it for review.
No. After consideration, NCQA removed the requirement for case managers to address life-planning activities at the start of the initial assessment (first contact). This FAQ replaces the previous FAQ issued on October 15, 2017 (which has been deleted) regarding first contact, and the workbook has been adjusted to accommodate the change.
No. Element A does not require organizations to implement a preventive behavioral healthcare program. The intent of factor 5 is that organizations collect data to determine if there are behavioral health issues that could be prevented if a program were to be implemented. Organizations collect data to meet Element A. Identifying the opportunity for such a program and implementing it is applicable to Element B.
The intent of the added language in factors 2 and 3 was to clarify the minimum information required for expedited appeals. NCQA recognizes these are new requirements, and for this reason, has added the following language to the scope of review:
Organizations must implement the changes in factors 2 and 3 for files processed on or after 11/1/18.
NCQA will post an update in December for the 2019 HP publication to reflect this change.
Yes. For non-file review requirements, if the arrangement was terminated more than 90 calendar days before submission of the completed survey tool, the organization is eligible for automatic credit for the portion of the look-back period when the NCQA-Accredited/ Certified/Recognized delegate conducted activities. For file review requirements, automatic credit is applied if the delegate processed (or handled) the file, regardless of when the delegation arrangement was terminated.
Yes. For non-file review requirements, if the arrangement was terminated more than 90 calendar days before submission of the completed survey tool, the organization is eligible for automatic credit for the portion of the look-back period when the NCQA-Accredited/ Certified/Recognized delegate conducted activities. For file review requirements, automatic credit is applied if the delegate processed (or handled) the file, regardless of when the delegation arrangement was terminated.
