NCQA Trainings

Length: 2.5 Hours

Covers Quantitative & Qualitative (Q&Q) analysis requirements and NCQA’s expectations. Walks through the Anatomy of Analysis and related terminology to establish a foundation for building a strong Analysis. Introduces the requirements of an Analysis report with emphasis on the detail needed to meet NCQA’s expectations. MHR Consultants offer valuable insights and examples throughout the presentation. Provides a pretraining exercise for attendees to complete to help reinforce learning.

Learning objectives include:

• Describe requirements for Q&Q analysis, including using valid methodology to collect data from multiple sources and establishing measures to compare results against performance goals or benchmarks.
• Explain requirements for measures not meeting goals, including identifying opportunities identified through root cause analysis, implementing interventions, and assessing effectiveness.
• Demonstrate the use of a template to document NCQA requirements of Q&Q analysis using the NET standards as an example.
• Describe how to develop and build a strong analysis using various techniques such as root cause analysis.
• Discuss common pitfalls of Q&Q analysis to avoid.

Length: 1.5 Hours

Presentation on additions, changes, scoring updates to the NCQA Health Plan Accreditation standards, relevant Policy Clarification Support (PCS), and FAQs. Attendees are encouraged to consider the impacts on their organization and the actions to be taken.

Learning objectives include:

• Recall changes to the standards for the new survey year.
• Identify how changes in the scope of review, look-back period, data sources, explanations, and scoring impact the organization's work.
• Identify impacts on your organization and actions to be taken.

Length: 2.5 hours

Covers the UM standards on appeals including appropriate handling of appeals, appropriate practitioner types to decide appeals, required documentation, denial letters, rationale for denials, and timeliness of reviews. Discusses the use of member-friendly language in notifications. Includes files included and excluded from review, insights from Policy Clarification Support (PCS) questions and FAQs. Emphasizes Must-Pass Elements.

Learning objectives include:

• Describe appropriate practitioner types who can make decisions for appeals.
• Specify appropriate documentation and rationale for appeal decisions.
• Explain how to write an appropriate rationale in denial letters.
• Recognize member-friendly language in notifications and when revisions are necessary.
• State timeframes for making decisions and reasons for extending appeal timeframes.
• Identify files to be included and excluded in the appeal file

Length: 2.5 Hours

A "boot camp" for those new to the NCQA Accreditation process. Explains standards terminology and main concepts found in the Standards & Guidelines, Appendices, and on the NCQA website.

Learning objectives include:

• Identify where essential features in the Policies and Procedures, Standards & Guidelines, and Appendices can be found.
• Identify the components of NCQA Standards, Must Pass Elements, and Critical Factors and their impact on organizations.
• Explain the survey process and differences between NCQA Interim, First, and Renewal surveys.
• Demonstrate how to find your organization’s Report Card and other NCQA resources.
  

Length: 2.5 hours

Target Audience: Complex Case Management staff. Covers file review requirements with an emphasis on drawing conclusions. Includes practice exercises and training points.

Learning objectives include:

• Apply knowledge of the standards, required data sources, and file requirements through participation in a hands-on exercise.
• Identify when the clock starts for 30 days/60 days in relationship to assessment.
• Distinguish the difference between an assessment statement and a conclusion.
• Identify the importance of file review, the points associated with them, and what files are included in the NCQA CCM survey file universe.

Length: 2 hours

Includes a detailed discussion on the credentialing/recredentialing standards, including significant changes with the 2025 standards, file reviews, delegation agreements, system controls, and missteps to avoid.

Learning objectives include:

• Identify appropriate sources for primary source verification (PSV).
• Identify practitioners requiring credentialing, as well as continuous monitoring, documentation, and reporting of practitioners who do not meet quality standards to appropriate authorities.
• Explain factors required to demonstrate annual monitoring and oversight of credentialing system controls.
• Specify the composition of a Credentialing Committee and the ongoing documentation needed.
• Discuss roles and responsibilities for CR/RR Delegation Agreements.
• Discuss the composition of credentialing and recredentialing file universes.

Length: 2 hours

Includes a comprehensive review of CVO standards and significant changes to the 2025 standards, Must Pass Elements, and Critical Factors.  Presents requirements for policies and procedures and the need for approval by a governing body.  Discusses Quantitative & Qualitative (Q&Q) analysis on the annual collection of data, such as on the timeliness of reporting, primary source verifications, and client satisfaction.  Reviews verification factors and time limits assessed during CVO file reviews.  Emphasizes requirements on system controls and the need to define, monitor, and analyze modifications of data.  Describes common missteps and ways to avoid them with tracking and monitoring tools.

Learning objectives include:

• Describe the requirements for a written quality improvement (QI) plan, including the need for SMART (specific, measurable, achievable, relevant, and time-based) goals for:
  • primary source verification (PSV)
  • system modifications
  • timeframe to complete client reports
  • client satisfaction scores
  • client complaints
• Explain the steps to conducting a Q&Q analysis and interventions needed for identified opportunities.
• Identify the verification factors assessed and related time limits for CVO file reviews.
• Discuss potential missteps related to data backup procedures, system controls, verifying the highest levels of education, reporting sanction information, and delegation agreements and ways to avoid them.

Length: 2 Hours

Applicable to a broad audience managing delegates and those responsible for running an NCQA-compliant delegation oversight program. Discusses agreements, vendors, predelegation, and ongoing monitoring.

Learning objectives include:

• Distinguish a delegate from a vendor.
• Describe organizational responsibilities for evaluating a potential delegate before a Delegation Agreement is finalized.
• Recall required components in a Delegation Agreement, such as roles, responsibilities, reporting, quality improvement, and system controls (UM, CR/RR).
• Explain roles and responsibilities for delegation oversight, including components necessary for running an NCQA-compliant delegation oversight program.

Length: 2.5–3.0 hours

Covers the UM 4-7 standards on denials including appropriate professionals, timeliness of decisions, clinical information,  appropriate rationale, denial notices, and the importance of using member-friendly language in notifications. Identifies files included and excluded from review, insights from Policy Clarification Support (PCS) questions, and FAQs. Emphasizes Must-Pass Elements.

Learning objectives include:

• Describe the requirements for appropriate professionals who can make decisions on denials for medical necessity, experimental and investigational treatments, and benefits.
• Specify appropriate clinical documentation, including the rationale for making a denial decision.
• Recognize the importance of using member-friendly language in notifications and when revisions are necessary.
• Identify appropriate reasons and timeframes for extensions of denial decisions.
• Identify the required language for the appeals process needed in the denial notification.
• Identify files to be included and excluded in the denial file universe.

Length: 3 Hours

The presenter walks through the HEA standards and Critical Factors with emphasis on collecting data on race, ethnicity, language, gender identity, and sexual orientation; stratification or segmentation of members; Quantitative and Qualitative (Q&Q) analysis; identifying and acting on opportunities; and annual evaluation.

 Learning objectives include:

• Identify data collection requirements and how individuals are stratified or segmented to identify opportunities and healthcare disparities.
• Recall how to compare membership needs to the existing practitioner network.
• Discuss the requirements for an annual analysis and evaluation of member needs and healthcare disparities.
• Identify appropriate actions to address health equity.

Explain requirements for HEA Delegation Agreements on health equity.

Length: 2 hours

Explains the movement from Health Equity Accreditation (HEA) to HEA Plus. Emphasizes the needs of subpopulations, identifying social risks of communities and individual social needs, engaging with partners on resources and interventions, and measuring the effectiveness of interventions.

Learning objectives include:

• Explain how the HEA Plus standards build upon HEA standards.
• Identify data requirements to identify populations and assess community social risks and individual social needs.
• Discuss the interconnections of social risks, social needs, service areas, community-based entities, partners, and stakeholders.
• Explain the roles and responsibilities of organizations and partners in delivering resources or providing interventions, as well as an accompanying Delegation Agreement, as appropriate.

Length: 2.5. Hours

Provides an overview of the LTSS standards and calls attention to high point requirements and data sources to meet during the look-back period. Explains the elements of an effective measurement and quality improvement program, emphasizes the importance of preventing unplanned transitions of care for high-risk individuals, and the optional use of HEDIS measures for quality measurement and performance. Discusses requirements on assessment, timeframes, and conclusions as applicable for file review.

Learning objectives include:

• Describe the steps to achieving LTSS Distinction with a recall of high-point standards and Critical Factors requirements to meet during the look-back period.
• Explain the elements of an effective LTSS measurement and quality improvement program, including annual reporting.
• Identify steps necessary for safe transitions of care.
• Identify assessment factors, timeframes, and conclusions as applicable for file review.
• Explain requirements when delegating NCQA-required LTSS activities.

Length: 2 hours each - (MBHO QI is 3 hours)

Training for MBHOs ranges from a comprehensive overview of the MBHO standards to individual training sessions on Care Coordination, Credentialing, Members’ Rights & Responsibilities, Quality Management & Improvement (QI), Utilization Management, and File Review.

• MBHO Standards Overview
• MBHO Care Coordination
• MBHO Credentialing
• MBHO Members’ Rights & Responsibilities
• MBHO Quality Management & Improvement
• MBHO Utilization Management
• MBHO File Review
• MBHO LTSS Distinction (Refer to LTSS Distinction)

Length: 2 Hours

Discusses standards on member satisfaction, member rights & responsibilities, quality and accuracy of information, website functionality, interpreter services, policies and procedures, assessment of non-behavioral and behavioral healthcare complaints and appeals, and importance of analyzing data on member experience.

Learning objectives include:

• Discuss member protections within a member's rights and responsibilities statement and how the statement is distributed to members.
• Explain requirements for assessing the quality and accuracy of marketing information provided to members, subscribers, and prospective members, such as on pharmacy benefits and utilization management.
• Explain the depth of analysis required for ME, including member satisfaction, nonbehavioral and behavioral healthcare complaints and appeals, and the quality and accuracy of content provided via the Internet, email, member services, and interpreter services.
• Recall how the evaluation of member experience is related to the analysis of practitioner networks.

Length: 2 Hours

Explains what a Model of Care (MOC) document is and its requirements for Special Needs Plans (SNPs) to describe its targeted populations, how the SNP coordinates care, its provider network contracted to provide health care services, and its quality improvement goals and plan. Discusses requirements and changes for the Calendar Year (CY) submission and the process by which organizations submit a MOC for approval, including how NCQA is the reviewer of MOCs for the Centers for Medicare & Medicaid Services (CMS). Describes how MOCs are scored at initial submission, possible cure options available, and final approval statuses. Provides insights on the detail required when writing a comprehensive MOC. 

Learning objectives include: 

• Explain what a MOC is and the four major areas of focus that must be described in detail.
• Discuss the process for submitting an initial MOC, the cure process, the final approval statuses, and the role NCQA has in reviewing MOCs for CMS.
• Recall the timeline for submitting a renewal and new SNP MOC.
• Explain the level of detail required for writing a comprehensive MOC.

Length: 2 Hours

Discusses NET standards on accessibility, availability and adequacy of practitioners and providers, continued access to care,  directories, and Critical Factors. Emphasizes requirements for cultural needs and preferences, and practitioners providing primary care, specialty care, and behavioral healthcare. Includes setting standards and goals, data collection, and methodology in preparation for Quantitative & Qualitative (Q&Q) analysis.

Learning objectives include:

• Review of Critical Factors for NET standards
• Describe the data collection process and methodology used for setting standards, ratios, and goals, as well as conducting a Q&Q analysis of the organization's networks.
• Explain how to assess the availability, accessibility, and adequacy of the primary, specialty, and behavioral health networks.
• Explain how the organization must adjust the availability of practitioners within its network based on the assessment of members’ cultural needs and preferences.
• Discuss how the analysis of member experience is integrated into the analysis of organization networks.
• Explain requirements for evaluating the accuracy and usability of physician and hospital directories.

Length: 2 Hours

Includes a discussion on a comprehensive approach to Population Health Management (PHM). Presents the need for population and member-level assessments that are used to develop a comprehensive PHM Strategy with targeted programs. Discusses metrics and analysis to evaluate the effectiveness of the PHM Strategy. Demonstrates how the Population Assessment, PHM Strategy, and Annual PHM Evaluation interrelate to promote positive health outcomes for its identified populations.  

Learning objectives include:

• Review of Critical Factors for PHM standards.
• Discuss the need for data collection from multiple sources to identify, assess, and segment/stratify the population to produce an Annual Population Assessment.
• Explain how the Annual Population Assessment informs updates to the PHM Strategy and the programs, activities, delivery support systems, and self-management tools identified within.
• Discuss clinical and cost/utilization metrics used for an Annual PHM Evaluation of Effectiveness and the need to identify barriers and opportunities.
• Describe requirements for Quantitative & Qualitative (Q&Q) analysis.
• Define file review requirements.

Length: 2 Hours

Discusses the transition from Disease Management Accreditation to Population Health Program (PHP) Accreditation for organizations providing condition- or population-based health programs. Emphasizes Must-Pass Elements for Systematic Review of Evidence and Measuring Clinical Quality, and Critical Factors for program descriptions and population assessments. Reviews annual requirements for segmenting populations and analyzing member experience data, participation rates, and health outcomes. Emphasizes the annual requirement for conducting Quantitative & Qualitative (Q&Q) analysis on at least two measures evaluating the impact of the program.

Learning objectives include:

• Describe the use of the Population Assessment to segment or stratify population data to identify targeted interventions for person-centered goals and update activities and resources.
• Describe the need for person-centered goals and how community resources are used to address individual needs, considering cultural and linguistic preferences.
• Explain the need to review new evidence every two years to develop the PHP programs and update eligibility for the programs, as well as the criteria for identifying eligible individuals, services offered, measurable program goals, program materials, and staff training.
• Explain requirements for conducting a Q&Q analysis on process and outcome measures, comparing results to a benchmark or goal, and interpreting results.
• Describe the process for identifying, resolving, and reporting individuals’ complaints about the PHP.  

Length: 2 Hours

Covers QI program requirements and continuity and coordination of care (medical, behavioral, between practitioners, and across settings). Includes requirements for the QI Program Description, Annual QI Work Plan, and Annual QI Evaluation using Quantitative & Qualitative (Q&Q) analysis.

Learning objectives include:

• Discuss requirements for the QI Program Description, Annual QI Work Plan, and Annual QI Evaluation.
• Explain requirements for measuring and evaluating continuity and coordination of medical care across settings and between practitioners, and between medical and behavioral health practitioners.
• Explain how interventions to improve continuity and coordination of care are evaluated for effectiveness over a three-year span using Q&Q analysis.
• Identify the roles and responsibilities of a quality oversight committee with practitioner involvement, as well as the requirements for diversity promotion and training.

Length: 2 Hours

Covers the content of the UM program, Must Pass Elements, Critical Factors, inter-rater reliability of UM decisions, rules on denial decisions, pharmacy management and annual UM Program Evaluation.  Excludes denial files, appeal files, system controls, and delegation of UM.

Learning objectives include:

• Review the Must Pass Elements and Critical Factors for UM.
• Identify the requirements for a UM Program Description and an Annual Evaluation of the UM Program.
• Explain the inter-rater reliability of individuals applying clinical criteria to UM decisions.
• Discuss the rules and language surrounding denials and appeals.
• Explain general requirements for UM Pharmacy Management and distinguish between medical and retail pharmacy benefits requirements.