FAQ Directory: Case Management

The first step to earning accreditation is a discussion with an NCQA program expert. Purchase and review the program resources, conduct a gap analysis and submit your online application.

Align your organization’s processes with the standards. NCQA conducts the survey and determines your accreditation status within 30 days of the final review.

See a step-by-step process.

CM 2014

If you are not currently accredited and want to learn more, contact NCQA. If you are currently accredited and want to talk to someone about your status or about renewing or adding accreditations, submit a question through My NCQA.

CM 2014

Find the Standards and Guidelines document in the NCQA eStore.

CM 2014

Case Management Accreditation is for organizations that provide a broad range of case management services for complex and high-risk populations. Organizations are eligible if it:

• Provides case management services for at least 6 months.
• Delivers 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.

CM 2014

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.

CM 2014

Use the NCQA Case Management Accreditation standards to perform a gap analysis and determine improvement areas. They provide a framework for implementing evidence-based best practices to ensure:

• Efficient and cost-effective case management processes and service delivery.

• Apply a QI process to improve operations.
• Maintain security of personal health information.
• Ensure patient access to well-qualified case management staff.
• Develop personalized, patient-centered care plans.
• Manage patients between care settings.
• Conduct systematic patient-centered assessments.
• Monitor patient to care goals progress.

CM 2013

NCQA Case Management Accreditation is a comprehensive, evidence-based program dedicated to quality improvement that evaluates the operations of case management programs in provider, payer or community-based organizations. NCQA-Accredited organizations demonstrate they have the internal processes and service delivery structure to cost-effectively meet the complex patient needs to improve health or functional capability.

CM 2013

More than forty organizations have earned NCQA Credentialing Accreditation. See the NCQA Report Card for a directory of accredited organizations.

CM 2014

The 2017 CM standards are effective on or after January 30, 2017. For organizations that have already scheduled a survey through June 30, the 2014 CM standards year will end on June 30, 2017. 

CM 2014

The organization must report the occurrence of any of the following actions by any federal or state regulatory authority:

• Issuance of Intermediate Sanctions and/or suspension of enrollment by CMS or any other federal or state regulatory authority.
• Issuance of any fine equal to or exceeding $50,000 related to Organization’s operations by CMS or any other federal or state regulatory authority.
• Issuance of any request for a corrective action by any federal or state regulatory authority where the substance of such corrective action relates to the Organization’s handling of utilization management decisions, network adequacy, benefit denials, complaints, grievances, appeals or other important patient safety matters. 

The above actions are referred to as the “final determination” within the Agreement.

CM 2010

Yes. The Agreement for Health Plan Accreditation Survey (the “Agreement”), specified in the “Organization’s obligations” section of the standards and guidelines, requires the organization to provide NCQA written notice within thirty (30) calendar days of the final determination by a state or federal agency with respect to request for corrective action, imposition of sanctions, changes in licensure or qualification status, if applicable, or violation of any federal or state law that affects the Scope of Review under the Standards and Guidelines. These are termed Reportable Events.

CM 2013

The organization must notify NCQA, in writing, within thirty (30) calendar days of the issuance of the notice of sanctions, issuance of a fine or issuance of a request for corrective action. 

The organization must also complete an annual attestation signed by an officer, or other authorized signatory of the organization, affirming that it has notified NCQA of all Reportable Events specified within the Agreement. NCQA-accredited health plans that reports HEDIS results include the attestation with its submission of the annual IDSS attestation submission for HEDIS® reporting.  Other health plans submit the completed attestation electronically to NCQA-Accreditation@ncqa.org. 

CM 2013