Provider Network Accreditation
Many health insurers rely on tiered and narrow networks to manage costs, and use third-party organizations to validate their networks. In response to these network designs, states and the federal government implemented regulations requiring a minimum level of access to care and services.
NCQA Provider Network Accreditation is a response to the emergence of vendor contracts for management of practitioner and provider networks. The program creates a framework for organizations to provide efficient, accurate and consistent network management and credentialing services.
Program standards and guidelines help organizations implement industry best practices to ensure:
- Network accessibility and transparency.
- Consistent monitoring of practitioner availability and accessibility of services.
- Efficient collection and analysis of member-experience data.
- Appropriate credentialing of practitioners and providers.
- Alignment with state requirements.
NCQA Provider Network Accreditation is designed for organizations that provide full-scope credentialing and network management services to employers, regulatory agencies, health plans and MBHOs.
The Accreditation Survey is 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 program standards.
NCQA-Accredited organizations that delegate network management and credentialing activities to an NCQA-Accredited service provider receive automatic credit for those functions in their Accreditation Survey.
To be eligible for Provider Network Accreditation, an organization:
- 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 Provider Network functions directly or through contractual agreement.
- Must perform Provider Network activities for at least 50% of the provider network.
Note: “Provider network” refers to the network of institutions and practitioners of clients and organizations.
Note: Organizations that meet Provider Network Accreditation requirements automatically earn Accreditation in Credentialing.
Organizations can earn the following NCQA Accreditation status levels:
- Accredited--3 years: NCQA awards a status of Accredited—3 years to organizations that demonstrate strong performance of the functions outlined in the Provider Network standards.
- Accredited--2 years: NCQA awards a status of Accredited—2 years to organizations that demonstrate performance of the functions outlined in the Provider Network standards.
- Denied: NCQA confers Denied Accreditation status on organizations whose programs for services and clinical quality do not meet requirements.
In-Depth Program Information