FAQ Directory

This applies to the following Programs and Years:

This applies to the following Programs and Years:

NCQA is introducing a new optional tier-based multi-site sampling approach for Person-Centered Care Plans to reduce Annual Reporting burden for larger organizations.

Organizations requesting multi-site sampling should submit requests through My.NCQA at least six months prior to the reporting date. For the initial rollout, NCQA will allow some flexibility and encourages organizations to submit requests as soon as possible prior to their reporting date. Beginning January 1, 2027, all requests should be submitted at least six months in advance of the reporting date. NCQA will review submitted requests and provide the sampled subset of sites back to the organization.

Organizations that would like to align the reporting dates of some, or all, of their sites should submit the request along with their multi-site sampling request, through My.NCQA. 

 Who is eligible:

• Organizations with 9 or more sites.
• Sites must share the same reporting date.

What this means:

• Eligible organizations may submit care plans from a subset of sites selected by NCQA
• Sampling is based on organization size.
• Upload 3 de-identified care plans for managed care patients per sampled site.
• Submitted care plans must represent 3 of the 5 care plan categories listed in CM 01: Identifying Patients for Care Management.

Note: This option applies to written care plans only. Practices must still report the number of patients who have a care plan per site.

If you are interested in using this option or would like to confirm eligibility, please contact your NCQA Representative via My.NCQA.
 

This applies to the following Programs and Years:

For PHM 2, Element B, factor 4 the organization must assess the needs of members with serious mental illness (SMI) and assess the needs of members with serious emotional disturbance (SED). If a member has both conditions, separate assessments are not required under factor 4. The organization determines if the member is assessed as a member with SMI or SED.

Applicable standards: 
•    Health Plan Accreditation – PHM 2, Element B
•    Behavioral Health Accreditation – PHM 2, Element B

This applies to the following Programs and Years:

UM approval and denial rates are calculated at the request level, not at the service or code level. A request is counted once in the denominator, regardless of how many services it includes. If any part of the request is approved, it counts as 1 approval. If any part is denied, it counts as 1 denial. Therefore, a partially approved and partially denied request is included in both the approval and denial rates.

For example, if one authorization request includes three CPT codes and one is approved while two are denied, the organization counts:

• 1 approval decision (count in the approval rate numerator),
• 1 denial decision (count in the denial rate numerator),
• 1 authorization request (count once in the approval and denial denominator).

As another example, if an organization made decisions on 300,000 total authorization requests, and:

• 200,000 were completely approved,
• 50,000 were partially approved/denied, and
• 50,000 were completely denied,

the rates would be calculated as follows:

• Overall approval rate: ((200,000 + 50,000) / 300,000) x 100 = 83%.
• Overall denial rate: ((50,000 + 50,000) / 300,000) x 100 = 33%.

The overall approval rate cannot exceed 100%, and the overall denial rate cannot exceed 100%. However, if an organization sums these two rates, the combined total may exceed 100%.

Applicable standards:

• Health Plan Accreditation – UM 1, Elements B-E
• Behavioral Health Accreditation – UM 1, Elements B-D
• Utilization Management Accreditation – UM 3, Elements B-E

This applies to the following Programs and Years:

No. To align with HPA, NCQA does not review communication to practitioners about the availability of UM criteria in UM 4, Element B in UM Accreditation or BHA. Instead, NCQA evaluates whether the organization makes the criteria available electronically (e.g., through an EHR, portal, or website). Acceptable evidence includes system reports or screenshots demonstrating how practitioners access the criteria at the point of care.

Applicable standards:

• Utilization Management Accreditation – UM 4, Element B
• Behavioral Health Accreditation – UM 2, Element B

This applies to the following Programs and Years:

The stem for HO 2, Element D should read as follows: "The organization's methods for evaluating member or patient disability status include:" 
Note: Although the stem appears in the e-publication version of the standards, it is not visible in the IRT version of the standards. This will be updated in the IRT version in August 2026.

Applicable standards:

• Health Outcomes and Community-Focused Care Accreditation – HO 2, Element D

This applies to the following Programs and Years:

• 20 are fully overturned, and
• 10 are partially overturned.

• Health Plan Accreditation – UM 1, Element E
• Behavioral Health Accreditation – UM 1, Element C
• Utilization Management Accreditation – UM 3, Element E
  

This applies to the following Programs and Years:

For the 2026 standards year only, NCQA is limiting the expanded monitoring requirement under CR 5, Element A, factor 3 to practitioners initially credentialed on or after July 1, 2026. Organizations are not required to apply this expanded monitoring requirement to practitioners credentialed before this date. 

For the 2027 standards year and beyond, the expanded requirement applies to all practitioners for surveys on or after July 1, 2027.

Applicable Standards:

• HPA: CR 5, Element A, factor 3
• BHA: CR 5, Element A, factor 3
• CRPN: CRA 5, Element A, factor 3 and CRC 12, Element B, factor 3

This applies to the following Programs and Years:

Yes. The "Handling Missing Values" table in the Related Information section is incorrect for the BR, NR and NQ audit designations. If any measure has a BR (Biased Rate), NR (Not Reported) or NQ* (Not Required) audit designation, it is assigned a rating of 0 and included in the calculation of the 3.0 average.

The information above is a correction to the Policy Update issued in March 2026 for QI 3, Element B.

*Accredited health plans may not use the NQ audit designation for measures included in the Health Plan Ratings measure list.

Applicable standards: 
•    Health Plan Accreditation: QI 3, Element B

This applies to the following Programs and Years:

No. For the Exchange product line, COVID-19 is not included in the Plan All-Cause Readmissions (PCR) risk adjustment calculations.

References of COVID-19 in the “Risk Adjustment Determination” narrative and introductory text of the Risk Adjustment Calculation section is an error. The PCR COVID-19 related discharge adjustments only apply to the Medicare product line for MY 2026.

This applies to the following Programs and Years:

Exchange MY 2026

This applies to the following Programs and Years:

No. For NCQA Health Plan Accreditation, NCQA reviews and scores UM 1, Elements B–H separately for each product line brought forward for Accreditation. Organizations may not combine any product lines—including commercial and Exchange—when reporting and evaluating UM rates for UM 1, Elements B–H.

Applicable standards: 

• Health Plan Accreditation: UM 1, Elements B-H.  
• Behavioral Health Accreditation: UM 1, Elements B-F. 
• Utilization Management Accreditation: UM 3, Elements B-H. 

This applies to the following Programs and Years: