Case Management Accreditation Requirements

NCQA Case Management Accreditation evaluates organizations performing case management services that typically focus on patients who are at high risk of experiencing costly hospitalizations or poor health outcomes because of complex social, behavioral or medical needs. Organizations must meet program criteria to pursue the accreditation.

FOCUS AREAS TO ENSURE HIGH QUALITY

NCQA Case Management Accreditation requirements ensure that organizations can consistently use efficient and cost-effective case management processes and delivery of services. Requirements cover these key areas:

  • Identification and assessment.
  • Care planning.
  • Care monitoring.
  • Care coordination.

To see all program requirements, get the Standards & Guidelines document.

REQUIRED ORGANIZATION SERVICES

The standards are designed for organizations providing case management services that include patient identification and assessment, care planning, care monitoring and care transitions to meet the needs of patients and their families.; for example:

  • Case management organizations.
  • Population health management organizations.
  • Health plans.
  • Managed behavioral healthcare organizations.
  • Provider-based organizations (e.g., medical groups, hospitals, integrated delivery systems).
  • Community care teams.

IS MY ORGANIZATION ELIGIBLE?

NCQA Case Management Accreditation is for organizations that provide a broad range of case management services for complex and high-risk populations:

  • Provide case management services for at least 6 months.
  • Deliver a broad range of case management services for complex or high-risk populations.
  • Perform functions covered in the accreditation program or arrange for the functions to be performed, directly or through a service agreement.
  • Manage valid sample size of individuals for NCQA evaluation, where standards require patient file review.

PROGRAM DESIGNATIONS

An organization seeking case management accreditation designates the program it wants evaluated; for example:

  • Complex case management.
  • Transitional case management.
  • High-risk and high utilization.
  • Hospital case management.
  • Organization defined programs.

CASE MANAGEMENT ACCREDITATION SUPPORT

Find information about NCQA Case Management Accreditation here:

  • Standards and Guidelines: The complete standards and guidelines, including the intent statement and scope of review.
  • Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organization’s survey readiness—the tool calculates your potential survey score.

Related Programs

NCQA offers several related programs for organizations eligible for the Health Plan Accreditation. Each program helps organizations improve their operations and initiatives in targeted areas and demonstrate their commitment to quality.

The programs are: Long-term Services and Supports Distinction and Multicultural Health Distinction.

LONG-TERM SERVICES AND SUPPORTS DISTINCTION

NCQA offers a Long-Term Services and Supports (LTSS) Distinction for organizations who provide case management services and coordinate social services for LTSS.

As the population ages, more states are seeking to increase accountability, improve quality and promote a cost-effective service delivery system that integrates care across all services—medical, behavioral, social and LTSS. It’s important for organizations to coordinate services effectively among caregivers, individuals, LTSS providers and clinicians. LTSS Distinction can support your organization in achieving these goals.

Visit the LTSS Distinction section for more information.

MULTICULTURAL HEALTH CARE DISTINCTION

NCQA offers a Distinction in Multicultural Health Care that identifies organizations—health plans, MCOs, MBHOs, wellness and population health organizations, and others—that lead the market in providing culturally and linguistically sensitive services, and working to reduce health care disparities.

Visit the Distinction in Multicultural Health Care section for more information.

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