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.
Practices are not restricted to referring patients only to practices with whom they have established agreements. NCQA reviews at least one example of a formal or informal agreement with a subset of specialists, but does not expect practices to have agreements with all specialists to whom they refer patients. The goal is that expectations are outlined in the agreement, in addition to expectations of timeliness/content of response from specialists.
PCMH 2017
The practice must demonstrate at least three examples demonstrating co-management arrangements, such as de-identified referral forms that include the arrangements or sections of the medical record specifying the clinician responsible for each component of care. For example, for a diabetic patient who is referred to a medical oncologist, the arrangement would identify which clinician manages the diabetes and which clinician manages the side-effects of the oncology treatment and their expectation for timely sharing of patient information.
PCMH 2017
Yes. Practices must have an agreement or documented process outlining the responsibilities of the referring provider and the specialist, even in an integrated system. It is essential that each provider understands the expectations and responsibilities of the referral, including the frequency and methods of communication.
PCMH 2017
A practice may use health plan data to identify patients if it is provided at least weekly and if at least 75 percent of the patient population is represented by the health plan. The practice may use data from more than one health plan as long as the plans collectively represent at least 75 percent of the practice population.
PCMH 2017
No. Practices are not required to identify all patients admitted to the hospital or ED, but they must have a process for identifying patients admitted to facilities used most often by their population. In addition to a documented process, practices must also submit a log or report demonstrating that patients were identified.
PCMH 2017
No. Although there is no requirement for a behavioral healthcare provider to be physically in the practice’s office, the behavioral healthcare provider must have at least partial access to the practice’s systems. Although the arrangements mentioned meet the intent of CC 09 (maintaining agreements with behavioral healthcare providers), they do not meet the requirements for this criterion.
If a practice site in an organization has integrated behavioral healthcare, the other sites in the organization may receive credit if there is also a process for their patients to access those behavioral healthcare services.
PCMH 2017
Yes. Practices that use integrated systems must demonstrate how specialists are notified of a referral request and how the referral status will be tracked (including the specialist’s report). Even if the same EHR is used by both the primary care practitioner and the specialist, evidence must clearly demonstrate how the requirements are met within the system.
PCMH 2017
