FAQ Directory

NCQA standards are a roadmap for improvement—organizations use them to perform a gap analysis and align improvement activities with areas that are most important to states and employers, such as network adequacy and consumer protection. Standards help plans in:

• Quality Management and Improvement.
• Population Health Management.
• Network Management.
• Utilization Management.
• Credentialing and Recredentialing.
• Members’ Rights and Responsibilities.
• Member Connections.
• Medicaid Benefits and Services.

HP 2020

NCQA Health Plan Accreditation is the most widely recognized, evidence-based program in the industry dedicated to quality improvement and measurement. It provides a comprehensive framework for organizations to align and improve operations in areas that are most important to states, employers and consumers. It’s the only evaluation program that bases results on actual measurement of clinical performance (i.e., HEDIS measures) and consumer experience (i.e., CAHPS measures).

HP 2020

The typical evaluation time frame is 12 months from application submission to decision, depending on an organization’s readiness. Some organizations may already be working within NCQA guidelines.

HP 2020

Any organization that provides managed health care services may apply for the NCQA Health Plan Accreditation if it meets the following criteria:

• Operates under an insurance license (e.g., HMO, POS, PPO, EPO), and
• Issues a contract for insurance for a defined population or contracts with an employer to provide managed care services for a self-insured population, and
• Provides services through an organized delivery system that includes ambulatory and inpatient health care sites, and
• Performs functions addressed in the standards (quality improvement, care coordination, utilization management, credentialing, member rights and responsibilities), either directly or through a service agreement, and
• Has a process for monitoring, evaluating and improving the quality and safety of care provided to its members, and
• Reports audited HEDIS results for designated HEDIS measures and CAHPS ratings and composites, as required for the selected Evaluation Option.

HP 2020

The standards, provide a framework for implementing best practices to improve:

• Quality Management and Improvement: Monitor, evaluate and improve the quality and safety of care.
• Care Coordination: Coordinate medical care and behavioral healthcare for its members.
• Utilization Management: Notifies members and practitioners about coverage decisions within required time frames.
• Credentialing and Recredentialing: Verifies the credentials of the practitioners in its network.

• Members’ Rights and Responsibilities: Written members’ rights and responsibilities policy exist.

To see the program requirement details, get the Standards & Guidelines document.

MBHO 2019

Pricing is based on multiple factors. Obtain full pricing information by submitting a request through My NCQA.

HP 2020

Pricing is based on multiple factors. Obtain full pricing information by submitting a request through My NCQA.

UM-CR 2019

UM-CR 2019

UM-CR 2019

The typical evaluation time frame is 12 months from application submission to decision, depending on an organization’s readiness. Some organizations may already be working within NCQA guidelines.

UM-CR 2019

Find the Standards and Guidelines document in the NCQA eStore.

UM-CR 2019

NCQA Managed Behavioral Healthcare Organization Accreditation is a comprehensive, evidence-based evaluation that reviews organizations to assure they use processes to deliver high-quality care and access. It provides a framework for organizations to align and improve operations in areas of quality improvement, care coordination, utilization management and credentialing and recredentialing and members’ rights.

MBHO 2019