FAQ Directory: Case Management

Filter Results
  • Save

    Save your favorite pages and receive notifications whenever they’re updated.

    You will be prompted to log in to your NCQA account.

  • Email

    Share this page with a friend or colleague by Email.

    We do not share your information with third parties.

  • Print

    Print this page.

8.20.2018 What are the Case Management Accreditation requirements?

Case Management Accreditation assesses an organization’s performance in the following key areas:

  • Identification and assessment
  • Care planning
  • Care monitoring
  • Care transitions
  • Measurement and quality improvement

CM 2014

8.20.2018 What other organizations have earned Case Management Accreditation?

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

CM 2014

8.20.2018 What is the price for Case Management Accreditation?

Pricing is based on multiple factors. Obtain full pricing information by submitting a request through My NCQA.

CM 2014

2.15.2017 Effective date for Case Management Accreditation 2017 and Termination date of Case Management Accreditation 2014 When will the 2017 CM standards be effective and when will the 2014 CM standards year end?

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

5.01.2015 Reporting Regulatory Actions Are health plans required to report regulatory actions taken against the organization?

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

5.01.2015 Notifying NCQA of Reportable Events How and when must the organization notify NCQA of Reportable Events?

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

5.01.2015 Specific Regulatory Actions to be Reported What specific regulatory actions must be reported?

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

8.29.2013 NCQA Complaint Review Process Does the Authorization NCQA receives from the complainant permit the organization to release information to NCQA and NCQA to the organization?

Yes. Release of information to the organization by NCQA and the organizations release of information to NCQA is covered. The organization is not required to seek subsequent release from the member/complainant because the authorization form covers both entities. However, the organization is free to seek their own authorization should they choose to do so.

CM 2013

8.29.2013 NCQA Complaint Review Process Does our current Agreement with NCQA permit NCQA to investigate complaints?

Yes, the current Agreement allows NCQA to investigate complaints relevant to the standards.

CM 2013

8.29.2013 NCQA Complaint Review Process Are complaints sent to a specific person at an organization?

Yes. Complaints are forwarded to the organizations Accreditation contact.

CM 2013

8.29.2013 NCQA Complaint Review Process When does the "30 calendar-day" response period begin?

The time period for response begins when the health plan receives the complaint from NCQA.

CM 2013

8.29.2013 NCQA Complaint Review Process Is the NCQA Complaint Review Process dated March 25, 2013 new?

No, this is not a new process or policy. NCQA has followed this process for handling complaints for more than a decade. In the interest of transparency, NCQA is sharing its policy with organizations.

CM 2013