Health Plan Accreditation 2020: New Requirements and Consumer Protections

In response to feedback from states and other stakeholders, NCQA identified some existing requirements that will be must-pass elements starting in 2020, as well as three new must-pass elements. These elements, in the Credentialing and Utilization Management categories, will strengthen consumer protections and help organizations better manage their procedures and risk.

New Must-Pass Elements


Organizations must earn “Met” on the following elements:

  • CR 3:
    • Element A: Verification of Credentials
    • Element B: Sanction Information
    • Element C: Credentialing Application
  • CR 4:
    • Element A: Recredentialing Cycle Length
  • CR 1:
    • New Element C: Credentialing System Controls. This element requires organizations to have policies and procedures describing their credentialing system controls.

These requirements help strengthen consumer protections by requiring plans to ensure that network clinicians are qualified to treat patients.

Utilization Management

Organizations must earn “Met” on the following elements:

  • UM 12:
    • New Element A: UM Denial System Controls
    • New Element B: UM Appeal System Controls

These elements help strengthen consumer protections by requiring organizations to have clear policies for denying coverage and for helping members appeal a denial of coverage.

Product Line Scoring

Starting in 2020, NCQA will report scores for standards by product line instead of averaged across product lines (read more about that here). As part of this change, there are several elements where NCQA will begin collecting and scoring evidence by product line. As a result, plans will need to submit evidence by product line for the following elements:

  • PHM 1, Elements A.
  • PHM 3, Element B.
  • PHM 6, Element B.
  • NET 3, Elements A–C.
  • UM 4, Elements C–E.
  • UM 5, Elements A–C.
  • UM 6, Elements A–C.
  • UM 7, Elements A–I.
  • UM 9, Elements A–D.
  • ME 2, Element A.
  • ME 7, Elements C, E.

This change helps clarify to plans, states and others where areas of concern lie, and helps plans better focus on areas that need improvement.

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