FAQ Directory

Find the Standards and Guidelines document in the NCQA eStore.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

NCQA Utilization Management Accreditation is designed to ensure that organizations pursuing accreditation can deliver fair and timely determinations to get the proper care to patients while effectively managing resources. The standards provide a framework for adopting industry best practices to objectively and efficiently evaluate the appropriateness of requested health care services.

This applies to the following Programs and Years:

The Standards and Guidelines document can be found in the NCQA eStore.

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: