2018 Utilization Management Accreditation
The new UM Accreditation program is effective on July 1, 2018.
The NCQA UM Accreditation program is available to a variety of organizations that perform UM activities. The standards, designed for organizations that provide full scope UM services, provide a framework for implementation of industry best practices to ensure:
- Fair and timely utilization evaluations using objective, evidence-based criteria
- Collection and use of relevant clinical information to make UM decisions
- Qualified health professionals assess requests and make UM decisions
- Alignment with state requirements
NCQA Accreditation demonstrates the quality of UM organization programs to employers, regulatory agencies, health plans and MBHOs.
The Accreditation Survey includes a rigorous evaluation conducted by a team of physicians and managed care experts. An independent review oversight committee of physicians analyzes the team’s findings and assigns an accreditation status based on the organization’s performance against standards.
To be eligible for UM Accreditation, organizations:
- Must not be licensed as an HMO, POS, PPO or EPO
- Must not be eligible for NCQA Accreditation as a health plan or an MBHO
- Must perform UM functions directly or through contractual agreement
- Must perform UM activities for at least 50% of the organization’s members
Note: “Members” refers to the membership of clients and organizations
• Accredited - 3 years: NCQA awards a status of Accredited – 3 years to organizations that demonstrate strong performance of the functions outlined in the UM standards.
• Accredited - 2 years: NCQA awards a status of Accredited – 2 years to organizations that demonstrate performance of the functions outlined in the UM standards.
• Denied: NCQA awards a status of Denied Accreditation to organizations that do not meet NCQA requirements.
In-Depth Program Information