Utilization Management Accreditation
To align with regulatory agency terminology, the NCQA Utilization Management Certification program is now the NCQA Utilization Management Accreditation program.
NCQA will release a new UM Accreditation program on July 24, 2017, with an effective date of July 1, 2018. Organizations planning a survey on or after July 1, 2018, must apply under the new program.
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 40% of the organization’s members
Note: “Members” refers to the membership of clients and organizations
Accreditation Statuses an Organization Can Achieve
Organizations can earn the following NCQA Accreditation status levels based on their performance against NCQA’s Standards and Guidelines.
- Accredited: NCQA awards a status of Accredited to organizations that meet or exceed 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