2025 Annual Reporting for PCMH Recognition

Introduction

Relevant supports the Annual Reporting process required by NCQA in order to maintain PCMH recognition. The Annual Reporting Process requires a practice to annually attest to continuous alignment with PCMH requirements, and submit evidence for a subset of key criteria supporting each of the PCMH concepts.

Annual Reporting Requirements

For Annual Reporting NCQA requires evidence for the following key criteria:

PCMH Concept	Criteria	Aligns with PCMH	How to find or implement in Relevant Read more about using the library
Team-Based Care and Practice Organization	AR-TC 1: PCMH Transformation Leads	TC 01	This is an attestation-only criterion.
	AR-TC 2: Structure and Staff Responsibilities	TC 02	This is an evidence upload criterion.
Knowing and Managing Your Patients	AR-KM 1: Comprehensive Health Assessment	KM 02	This is an attestation-only criterion.
	AR-KM 2: Diversity	KM 09	Relevant Standard Report: Patient Demographics Default status: published (hidden) [healthcenter].relevant.healthcare/report_builder/reports/38
	AR-KM 3: Community Resource Needs	KM 21	This is an attestation-only criterion.
Patient-Centered Access and Continuity	AR-AC 1: Clinical Advice Documentation	AC 05	This is an attestation-only criterion.
Care Management and Support	AR-CM 1: Identifying Patients for Care Management	CM 01	This is an attestation-only criterion.
	AR-CM 2: Care Plans for Care Managed Patients ¹	CM 04	Relevant Library Measure: Care Plans for Care Managed Patients [healthcenter].relevant.healthcare/library/measures/837
Care Coordination and Care Transitions	AR-CC 1: Referral Management	CC 04	This is an attestation-only criterion.
	AR-CC 2: Post-Hospital/ED Visit Follow-Up	CC 16	This is an evidence upload criterion.

Performance Measurement and Quality Improvement (AR-QI)

AR-QI 1: Clinical Quality Measures (Aligns with PCMH QI 01)

Select five measures across the four categories with at least one measure of each type.

Category	Measure	CMS eCQM #	How to find in Relevant
Immunization	Childhood Immunization Status: Combo 10	CMS 117	Relevant Standard Measure
Chronic / Acute Care	Diabetes Eye Exam ¹	CMS 131	Relevant > Library > Measures In the Tags filter, select “ PCMH Standardized Measures”
	HIV Viral Suppression	CMS 314
	Controlling High Blood Pressure	CMS 165	Relevant Standard Measures
	Diabetes HbA1C Poor Control (>9%)	CMS 122
	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS 347
Behavioral Health	Screening for Depression and Follow-Up Plan	CMS 2
	Depression Remission at Twelve Months	CMS 159
	Initiation of Substance Use Disorder Treatment	CMS 137
	Engagement of Substance Use Disorder Treatment	CMS 137
Preventive	Cervical Cancer Screening	CMS 124
	Colorectal Cancer Screening	CMS 130
	Breast Cancer Screening	CMS 125
	BMI Screening and Follow-Up Plan	CMS 69
	Tobacco Use: Screening and Cessation Intervention	CMS 138
	HIV Screening	CMS 349
	Weight Assessment and Counseling for Nutrition & Physical Activity for Children and Adolescents	CMS 155
	Chlamydia Screening in Women ¹	CMS 153	Relevant > Library > Measures In the Tags filter, select “ PCMH Standardized Measures”

AR-QI 2: Resource Stewardship Measures (Aligns with PCMH QI 02)

Select 2 measures. One from each category.

Category	Measure	CMS eCQM #	How to find in Relevant
Health Care Costs	Appropriate Testing for Pharyngitis	CMS 146	Relevant > Library > Measures In the Tags filter, select “ PCMH Standardized Measures”
	Appropriate Treatment for URI	CMS 154
Care Coordination	Closing the Referral Loop: Receipt of Specialist Report ²	CMS 50
	Documentation of Current Medications in the Medical Record ²	CMS 68

AR-QI 3: Patient Experience Measure (Aligns with PCMH QI 03)

Relevant will create Custom Reports as necessary to fulfill this requirement. Partnering with Health Centers with patient experience data will be particularly advantageous as we consider the addition of patient experience data to our data model.

Relevant is happy to assist with this mapping as needed; for assistance, please email us at support@relevant.healthcare.

Measures Under Development:

Fall: Screening for Future Fall Risk
Sexually Transmitted Infection (STI) Testing for People with HIV
Anti-depressant Medication Management
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Dementia: Cognitive Assessment

Measure may require mapping of new or unmapped Data Elements. Find details in the Notes section of the Measure. ↩ ↩² ↩³
Measure requires mapping of additional columns on pre-existing tables. Details included in the Notes section of the Measure. ↩ ↩²