FAQ Directory: Case Management

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

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

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

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

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

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 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

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

NCQA considers entities that perform relevant functions to be eligible for NCQA CM Accreditation, including, but not limited to: CM organizations, population health management organizations, health plans (HP), managed behavioral healthcare organizations (MBHO), provider-based organizations– including medical groups, hospitals, integrated delivery systems, patient-centered medical homes (PCMH) and accountable care organizations (ACO), community care teams.

CM 2014

For CM 2, Element E, which is a file review element, NCQA is looking for documentation of whether or not you completed the applicable activities listed in CM 2, Element D: Initial Assessment Process. For your program, you would note in your documentation that certain factors are not applicable for that particular patient population.

CM 2014

While NCQA does not include in requirements that your staff to hold specific certifications for case management, NCQA does have standards requiring organizations to verifying licensure for clinical staff who are required to maintain a license. "Clinical staff" is defined as individuals who are licensed to treat patients. Organizations would determine which certifications are appropriate for staff serving their patient population.

CM 2014