FAQ Directory

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.

This applies to the following Programs and Years:

In general, any organization that operates a physician measurement program or hospital transparency program is eligible for certification. This includes, but is not limited to:

• Health plans.
• Provider networks.
• Collaborative measurement organizations.
• Information providers.

Organizations that meet these criteria are also eligible:

• Operate a physician measurement program or hospital transparency program, as defined in the standards.
• Are responsible for responding to complaints from consumers and to requests for change from physicians or hospitals based on the organization’s actions.
• Comply with applicable federal, state and local laws and regulations, including requirements for licensure.
• Operate without discrimination based on sex, race, creed or national origin.

Note: There are other eligibility criteria. Refer to the standards and guidelines document available in the NCQA eStore.

This applies to the following Programs and Years:

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

Find the Standards and Guidelines document in the NCQA eStore.

This applies to the following Programs and Years:

Several organizations have earned NCQA Provider Network Accreditation. See the NCQA Report Card for a directory of accredited organizations.

This applies to the following Programs and Years:

Meeting NCQA Medicaid Module standards can help organizations:

• Streamline compliance activities. Compliance activities are reduced when the state uses NCQA Health Plan Accreditation and Medicaid Module standards as part of the Medicaid quality review.
• Become more efficient. Reallocate key quality review resources to other Medicaid priorities.

This applies to the following Programs and Years:

Find the standards and guidelines document, the survey tool and the application in the NCQA eStore.

This applies to the following Programs and Years:

More than 50 organizations have earned NCQA Utilization Management Accreditation. See the NCQA Report Card for a directory of accredited organizations.

This applies to the following Programs and Years:

NCQA’s Physician and Hospital Quality Certification program evaluates how well organizations measure and report the quality and cost of physicians and hospitals. NCQA looks at measurement processes and methodology, transparency, collaboration and the balance between quality/cost when using the information to make decisions.

This applies to the following Programs and Years:

Health plans increasingly use physician quality information for value-based contracting, pay-for-performance programs, provider networks, physician tiering and more. Because payers make decisions based on these data, how data are measured is important.

The NCQA Certification process helps ensure that health plans and provider networks make decisions based on sound methodology, and assures patients and physicians that those decisions are transparent and that quality is not sacrificed to cost.

This applies to the following Programs and Years:

The standards and guidelines document is the publication that contains the requirements for certification. You can download this document for free through the NCQA eStore.

These standards include:

For Physician Quality:

• Measures and Methods: Evaluates how an organization measures the quality and affordability of care provided by physicians, including:
  • Use of standard sources.
  • How cost is measured.
  • Defined methodologies.
  • Adherence to key principles.
  • Frequency of measurement.
• Working with Physicians: Evaluates the transparency of the physician measurement program and how organizations work with physicians to respond to requests for corrections or changes.
• Working with Customers: Looks at the organization’s level of transparency with customers (consumers and purchasers) regarding the details of its physician measurement program, and whether the organization works with consumers to address complaints.
• Program Input and Improvement: Ensures that the organization seeks input and feedback on the design of its physician measurement program and on its reporting process, to improve the program’s value to physicians and customers.

For Hospital Quality:

• Hospital Performance: The organization provides consumers and purchasers with information about how hospitals perform, to help them make decisions based on quality and cost. Organizations are evaluated on:
  • Hospital performance data: How they report payer quality and cost information to customers.
  • Decision support tools: Whether hospital reports support informed decision making.
  • Availability of information to customers: Whether they make hospital performance information available to consumers, purchasers and others.
  • Scope of hospitals: How they report performance information on hospitals in the network.
  • Working with hospitals on reporting: Whether they work with network hospitals on reporting.
  • Information about measurement: Whether they make information available about performance-based payments.
  • Feedback on Customer Reports: Whether they seeks customer feedback, with the goal of improving the usefulness of hospital performance reports.

This applies to the following Programs and Years: