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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7.01.2025 What changes were made to the PCMH Standards and Guidelines for Version 11?

KM 02: Comprehensive Health Assessment Added a note, "All patients need all the components addressed in their medical record. Providing components from multiple patients does not meet the intent."​
KM 03: Depression Screening Added this clarification in the adolescent section, "Screening under age 12 may be conducted as clinically indicated."​
KM 14: Medication Reconciliation and
KM 15: Medication Lists		 The thresholds have changed from more than 80% to more than 90%.
KM 26: Community Lists Added, “The practice maintains a list of resources supported by the community and/or payers by selecting five topics or service areas of importance to the patient population.”
AC 01: Access Needs and Preferences Added more detailed information, “The practice annually surveys patients to determine if existing access (e.g., days open, hours of operation, modalities, etc.) is meeting the needs of the patient population. The screening also collects input of the patient to understand their preferences.”
CM 04: Person-Centered Care Plans Clarified that the required elements include the patient’s medication list and management as well as the patient’s comprehensive problem list.
Also, provided more guidance on a care plan’s requirements.
CM 10: Person-Centered Outcomes Approach Added, “If the organization chooses to use PROMs to track goals, NCQA recommends that the organization have at least 8–10 PROMs for clinicians to choose from, for use with patients.”
CC 04: Referral Management Added, “The practice uses the patient's medical health history and clinical protocols to determine when a referral is necessary.”
Also, “The organization confirms that referrals are local to the patient's community of residence, and whether the referral is in the patient's practitioner network.”
Additionally, “The expectation is that the specialist/ancillary clinician return visit documentation so the loop can be closed”
CC 08: Specialist Referral Expectations
And CC 09: Behavioral Health Referral Expectations		 Added, “The organization communicates referral expectations to patients, including the contact information of the referring clinician and additional instructions or education, if applicable.”
CC 21: External Electronic Exchange of Information Added D. Clinical data exchange with payers.
This is worth 1 elective credit point.
QI 01: Clinical Quality Measures and
QI 02: Resource Stewardship Measures		 Added a documented process to the evidence.
Cadance Thresholds Please see additional FAQ for cadence thresholds, added to 45 existing criteria.

Criteria Retirement:
Eight criteria were identified as no longer serving a substantial purpose or adding meaningful value to primary care, leading to their retirement from the PCMH program.

Criteria Identification and Title
TC 03: External PCMH Collaborations
TC 09: Medical Home Information
KM 08: Patient Materials
KM 18: Controlled Substance Review
KM 25: School/Intervention Agency Engagement
KM 28: Case Conferences
CC 12: Co-Management Arrangements
QI 18: Electronic Submission of Measures

This applies to the following Programs and Years:
PCMH 2017

6.16.2025 Conducting Audit of Effectiveness Quarterly If an organization chooses to complete its audit and analysis for the Information Integrity requirements quarterly, may it also complete the audit of effectiveness quarterly?

Yes. Organizations that choose to conduct their audit and analysis for Information Integrity more frequently than annually (i.e., quarterly), may also conduct the follow-up audit of effectiveness more frequently. The audit must be within the 3–6 month time frame prescribed by NCQA. 

Applicable Standards: 

HP: CR 8, Element C; CR 8, Element D, factor 2. UM 12, Element D, UM 12, Element E, factor 2; UM 12, Element F, UM 12, Element G, factor 2. 

CRPN: CR 2, Element C, CR 2, Element D, factor 2. 

MBHO: CR 8, Element C; CR 8, Element D, factor 2. UM 11, Element D, UM 11, Element E, factor 2; UM 11, Element F, UM 11, Element G, factor 2. 

This applies to the following Programs and Years:
HP 2025|CRPN 2025|MBHO 2025

6.16.2025 Evidence for QI 3, Element D: Exchange Reporting What types of evidence may an organization submit to demonstrate reporting of the required measures for QI 3, Element D?

Organizations must provide an IDSS report and/or a CMS Proof Sheet as evidence of reporting the required measures for the Exchange product line in QI 3, Element D.

This applies to the following Programs and Years:
HP 2025

6.16.2025 QI 3, Element A: Applicability of Behavioral Healthcare Reported Measures How can an organization that reports measures for QI 3, Element A meet the 50% threshold if behavioral healthcare services are carved out and the organization therefore has a “No Benefit” audit designation for 6 of the 10 measures? 

In this example, the organization may demonstrate compliance with QI 3, Element A by providing evidence that it reported 50% of required measures it is capable of reporting. The organization would be required to report a valid, numeric rate for at least 50% of the required nonbehavioral health measures (i.e., 2 of the 4).

This applies to the following Programs and Years:
HP 2025

6.16.2025 Clarifying the Definition of “Threshold Languages” How does NCQA define “threshold languages” for CM-LTSS Accreditation and LTSS Distinction in Health Plan Accreditation?

NCQA defines threshold languages as “all languages other than English spoken by 5% of the population or by 1,000 eligible individuals, whichever is less.” 

Applicable Standards: 

HP: LTSS 1, Element D, factor 2. 

CM-LTSS: LTSS 2, Element A, factor 2. 

This applies to the following Programs and Years:
CM-LTSS 2024|HP 2025

6.13.2025 TotalKnown Data Element for Language Diversity of Membership (LDM) Is the TotalKnown data element in Table LDM-A-1/2/3 and Table LDM-B-1/2/3 a calculated data element?

Yes. This data element is a calculated field in IDSS, and it should be shaded gray. We will correct this in the release of the MY 2026 Volume 2 Technical Specifications.

This applies to the following Programs and Years:
HEDIS MY 2025

6.13.2025 Direct reference code POS 81 for Adult Immunization Status (AIS-E) POS code 81 is included in the AIS-E measure specification but is not included in the Direct Reference Code tab of the VSD. Should the code be used when reporting Adult Immunization Status for MY 2025?

Yes. As described in Numerator 5—Immunization Status: Hepatitis B, use POS code 81 to exclude laboratory claims when identifying members with a history of hepatitis B illness. POS code 81 was mistakenly omitted from the Direct Reference Code tab of the VSD. Because the information needed for reporting is in the measure specification, NCQA does not intend to reissue the VSD.

This applies to the following Programs and Years:
HEDIS MY 2025

5.15.2025 CAQH Application and Antidiscrimination Statement Has NCQA been in communication with CAQH about including the new NCQA requirements for race, ethnicity and language on its application?

Yes. NCQA has worked with CAQH to add a notice to its practitioner- and customer-facing provider credentialing applications, recognizing that discriminatory uses of race, ethnicity and language data are prohibited. CAQH is going live with the application update on 7/1/25.

The use of the CAQH application will be acceptable to meet CR 3, Element C, factor 6: Race, ethnicity and language in the 2025 Health Plan Accreditation standards and guidelines (and applicable products).

This applies to:
HPA: CR 3, Element A, factor 6
CRPN: CRA 3, Element A, factor 6, CRC 10, Elements A, factor 6
MBHO: CR 3, Element A, factor 6

This applies to the following Programs and Years:
HP 2025|CRPN 2025|MBHO 2025

5.15.2025 Credentialing Application: Race, Ethnicity and Language (REL) Are separate fields required for race, ethnicity and language? For example, is the CAQH application acceptable to meet CR 3, Element C, factor 6, as the CAQH application collects race and ethnicity under one field and language in another?

The requirement is for the application to have separate fields to enter responses for each of these three data points (race, ethnicity, and language). However, it would be acceptable to group these into one question if the application prompts the user to provide separate responses for race, ethnicity and language. 

Responses provided through the CAQH online portal for credentialing data application are acceptable. Although the online portal supporting the credentialing application groups the responses for race and ethnicity into one field, the practitioner is prompted to provide separate responses within the system. When a practitioner chooses his/her race, the practitioner is then prompted to provide his/her ethnicity information. Language is captured via a separate field.  

This applies to:
HPA: CR 3, Element A, factor 6
CRPN: CRA 3, Element A, factor 6, CRC 10, Elements A, factor 6
MBHO: CR 3, Element A, factor 6

Note:  A related question was posted on 3/17/2025: “Credentialing Application: Race, Ethnicity and Language (REL).” This FAQ is an update to that post. 

This applies to the following Programs and Years:
HP 2025|CRPN 2025|MBHO 2025

5.15.2025 Vaginal Specimen Source for the CCS and CCS-E measures Does an HPV or Pap test that has a vaginal sample source meet criteria for the numerator?

Yes. If the HPV or Pap test sample source is vaginal, and can be billed to an appropriate code in the value sets, it may be used to meet criteria.

This applies to the following Programs and Years:
HEDIS MY 2024, 2025

5.15.2025 Medication List in Deprescribing of Benzodiazepines in Older Adults (DBO) In the MY 2025 Medication List Directory, three codes (NDC codes 00378027701, 00378027705; RxNorm code 856792) are included in both the Chlordiazepoxide 10 MG Medications List and the Chlordiazepoxide 25 MG Medications List. Should the codes be included in both lists?

No. The codes are for “amitriptyline hydrochloride 25 MG/chlordiazepoxide 10 MG Oral Tablet.” They belong only in the Chlordiazepoxide 10 MG Medications List. NCQA re-released the MY 2025 Medication List directory on May 15, 2025, to incorporate this update. NCQA’s Measure Certification program confirmed that certification organizations deleted the codes from the Chlordiazepoxide 25 MG Medications List. No changes to the current process are necessary.

This applies to the following Programs and Years:
HEDIS MY 2025

4.15.2025 Using software to make medical necessity approval decisions May organizations use software to make medical necessity approval decisions?

Yes, if the software uses the organization’s clinical criteria, policies and procedures and benefit package information, and the organization maintains control over the software implementation. Organizations may not use the software to make any denial decisions; those must be made by an appropriate clinical professional. Appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.

NCQA considers the use of external software to make approval decisions to be a vendor relationship for applicable requirements (e.g., UM 4, Element F). Refer to Appendix 3: Delegation and Automatic Credit Guidelines for additional information.

This applies to the following Programs and Years:
HP 2025|MBHO 2025|UM-CR-PN 2025