FAQ Directory

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.

This applies to the following Programs and Years:

NCQA Utilization Management Accreditation is a comprehensive program that evaluates the operations of organizations providing full-scope utilization management services, which include using evidence-based criteria, relevant clinical information and qualified health professionals to make utilization management decisions.

This applies to the following Programs and Years:

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

This applies to the following Programs and Years:

NCQA Provider Network Accreditation is a comprehensive, evidence-based program dedicated to quality improvement that evaluates the accessibility and transparency of organization networks and credentialing of practitioners and providers. NCQA-Accredited organizations demonstrate they have the internal processes and procedures to effectively manage access to care and member experience while ensuring that practitioners and providers are appropriately credentialed.

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:

More than 30 organizations have earned NCQA Health Plan Accreditation. See the NCQA Report Card for a directory of accredited organizations.

This applies to the following Programs and Years:

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.

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:

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.

This applies to the following Programs and Years:

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

This applies to the following Programs and Years:

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).

This applies to the following Programs and Years:

Any organization that provides managed health care services may apply for the NCQA Managed Behavioral Healthcare Organization Accreditation if it meets the following criteria:

• Has been in operation for at least six months, and
• Enrolls or receives enrollment of an identifiable eligible population that is eligible to access the network, and
• Provides comprehensive behavioral health care services through an organized delivery system across a continuum of care, 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.

This applies to the following Programs and Years: