POs that seek certification must select Evaluation Options (QI, UM, CR) for which they wish to be certified; however, all POs are surveyed against the following core standards.
Agreement and Collaboration With Health Plans [HPs] (PO 1)
Confidentiality Policies (PO 2)
To be eligible for certification for a specific Evaluation Option, the PO must perform all functions associated with each standard in the chosen option. NCQA determines on an individual basis when a standard or element within a standard does not apply.
1. Agreement and Collaboration with Health Plans (PO 1)
- Has the organization worked with the client to develop a mutually agreed-upon document that describes each party’s responsibilities, delegated activities, frequency of reporting to client, process by which the client evaluates the organization and the remedies available to the client if the client does not fulfill its obligations?
- Has the organization provided the client with documents necessary to conduct oversight and provided the client with reports at agreed-upon frequency?
- Has the organization cooperated with the client’s efforts to implement quality improvement and other activities?
- Has the organization given the client access to its medical records?
2. Confidentiality Policies (PO 2)
- Has the organization implemented confidentiality policies and procedures to maintain confidentiality of information for any purpose and protect medical records?
- Has the organization developed policies to obtain members’ permission before releasing confidential information, do the organization’s practitioner contracts address confidentiality of member information and records?
2009 Evaluation Options
A Summary of What NCQA Looks for When It Reviews a PO
Note: Some standards from other NCQA programs are not part of PO Certification; therefore, standard numbers and categories may vary between products.