NCQA makes disaster accommodations on a case-by-case basis during the accreditation survey process.
The organization must document the events from the disaster that prohibited your organization from meeting the standard/element. During the accreditation survey, the surveyor will document all findings which will be reviewed by our Review Oversight Committee (ROC) to determine if any accommodations or exceptions should be granted.
The organization should communicate with the assigned ASC if accommodations are requested.
HP 2025
For commercial, Medicare and Medicaid organizations to be able to calculate an average rating for QI 3, Element B, they must receive a Health Plan Ratings scoresheet. Only organizations that have complete data receive a rating and scoresheet. Therefore, organizations that do not receive an HPR scoresheet will be scored NA in QI 3, Elements B and C.
The organization must demonstrate that it meets the requirements in QI 3, Element A, and will not be eligible for NA for that element.
Similarly, if an Exchange organization either does not report QRS data to CMS or receives NR for the Exchange product line because it does not have a valid rate for any required QRS measure in Element D, it must demonstrate data exchange in QI 3, Element A.
HP 2025
For Health Plan Accreditation 2025, the organization is only required to take action on one measure for Health Plan Ratings for which it received a 0 or 1 for QI 3, Element C, and one measure required for QRS in QI 3, Element D. However, if the organization chooses to address more than one measure in its improvement plan, the guidance regarding using one action to address all measures applies but NCQA will only score taking action on one measure for the 2025 standards year.
HP 2025
No. Organizations are still required to monitor for system controls. The NA for the system controls policies and procedures requirement (e.g., UM 12, Element A, factor 7, in Health Plan Accreditation) does not affect an organization’s ability to meet the corresponding system controls monitoring requirement (e.g., UM 12, Element B in Health Plan Accreditation); it means the organization is not required to describe the monitoring process in its policies and procedures, but must monitor that its systems are protecting data from unauthorized modifications. Also, as noted in “Related information” in the monitoring requirements (e.g., UM 12, Element B in Health Plan Accreditation), NCQA only reviews specific components for monitoring (e.g., for UM, NCQA reviews that the organization monitored receipt and notification dates).
Note: The referenced memo is on the NCQA website at https://www.ncqa.org/wp-content/uploads/2025-Retroactive-Changes-Memo_Final.pdf. It applies to the 2024/2025 standards year only; no exceptions (NA scores or other changes) will be made for the 2023 or prior standards years. Surveys conducted on standards prior to 2024 standards will be reviewed and scored accordingly; any corrective actions issued prior to the 2024 standards still apply
HP 2024
No. NCQA UM standards do not allow the use of AI to make medical necessity denial decisions, or any appeal decisions.
If an organization uses AI in the UM process, medical necessity review requires that denial decisions be made only by an appropriate clinical professional and appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.
HP 2024
Typically, no as health plan staff are not practicing practitioners within the health plan's network. The intent of collaboration requirements are for organizations to demonstrate collaboration between their behavioral healthcare delivery system (network practitioners) and medical care delivery system (network practitioners).
Note: Demonstrating collaboration with an MBHO is acceptable for the collaboration with “behavioral healthcare practitioners” component of the requirement.
HP 2024
Yes. NCQA uses language in the Explanation that organizations may use more general or extensive language to query practitioners about impairment.
Note: This question was previously posted on August 15, 2023 and reevaluated by NCQA. This FAQ answer replaces the previously posted response.
HP 2024
Yes, the following CAQH question meets the intent of the requirement in CR 3, Element C, factor 2:
HP 2024
