FAQ Directory: Health Plan Accreditation

For purposes of QI 2, Element C, behavioral health organizations include organizations that provide or manage behavioral health services, such as managed behavioral health organizations (MBHOs), inpatient psychiatric facilities and behavioral health clinics.  

A hospital contract alone is not sufficient to meet the intent of the requirement because a hospital relationship may only provide limited, episodic data and may not reflect comprehensive data integration across the behavioral health continuum. 

However, if the organization can demonstrate that the contracted entity provides behavioral health services beyond limited or episodic inpatient care and that the behavioral health data support assessment of care and outcomes for the behavioral health population, it may be considered a behavioral health organization for QI 2, Element C. 

Applicable standards: 

• Health Plan Accreditation – QI 2, Element C. 

This applies to the following Programs and Years:

Both statements apply to UM decisions, but they reflect different review processes and therefore have different starting points for when assessing timeliness purposes. 

• Statement 1 applies when the organization receives a UM request. Timeliness is measured from the date the request is received from the member or the member’s authorized representative. 
• Statement 2 applies to subsequent reviews of previously approved urgent concurrent care when the organization has procedures for conducting ongoing reviews. In these cases, no new request is submitted. Because the organization initiates the review based on its established procedures, timeliness is measured from the date the ongoing review is conducted. 

Applicable standards: 

• Health Plan Accreditation – UM 5, Elements A-C. 
• Behavioral Health Accreditation – UM 5, Element A. 
• Utilization Management Accreditation – UMA 1, Element B; UMA 2, Element B; and UMA 3, Element B.

This applies to the following Programs and Years:

Yes. The "Handling Missing Values" table in the Related Information section is incorrect for the BR, NR and NQ audit designations. If any measure has a BR (Biased Rate), NR (Not Reported) or NQ* (Not Required) audit designation, it is assigned a rating of 0 and included in the calculation of the 3.0 average.

The information above is a correction to the Policy Update issued in March 2026 for QI 3, Element B.

*Accredited health plans may not use the NQ audit designation for measures included in the Health Plan Ratings measure list.

Applicable standards: 
•    Health Plan Accreditation: QI 3, Element B

This applies to the following Programs and Years:

• 20 are fully overturned, and
• 10 are partially overturned.

• Health Plan Accreditation – UM 1, Element E
• Behavioral Health Accreditation – UM 1, Element C
• Utilization Management Accreditation – UM 3, Element E
  

This applies to the following Programs and Years:

UM approval and denial rates are calculated at the request level, not at the service or code level. A request is counted once in the denominator, regardless of how many services it includes. If any part of the request is approved, it counts as 1 approval. If any part is denied, it counts as 1 denial. Therefore, a partially approved and partially denied request is included in both the approval and denial rates.

For example, if one authorization request includes three CPT codes and one is approved while two are denied, the organization counts:

• 1 approval decision (count in the approval rate numerator),
• 1 denial decision (count in the denial rate numerator),
• 1 authorization request (count once in the approval and denial denominator).

As another example, if an organization made decisions on 300,000 total authorization requests, and:

• 200,000 were completely approved,
• 50,000 were partially approved/denied, and
• 50,000 were completely denied,

the rates would be calculated as follows:

• Overall approval rate: ((200,000 + 50,000) / 300,000) x 100 = 83%.
• Overall denial rate: ((50,000 + 50,000) / 300,000) x 100 = 33%.

The overall approval rate cannot exceed 100%, and the overall denial rate cannot exceed 100%. However, if an organization sums these two rates, the combined total may exceed 100%.

Applicable standards:

• Health Plan Accreditation – UM 1, Elements B-E
• Behavioral Health Accreditation – UM 1, Elements B-D
• Utilization Management Accreditation – UM 3, Elements B-E

This applies to the following Programs and Years:

For the 2026 standards year only, NCQA is limiting the expanded monitoring requirement under CR 5, Element A, factor 3 to practitioners initially credentialed on or after July 1, 2026. Organizations are not required to apply this expanded monitoring requirement to practitioners credentialed before this date. 

For the 2027 standards year and beyond, the expanded requirement applies to all practitioners for surveys on or after July 1, 2027.

Applicable Standards:

• HPA: CR 5, Element A, factor 3
• BHA: CR 5, Element A, factor 3
• CRPN: CRA 5, Element A, factor 3 and CRC 12, Element B, factor 3

This applies to the following Programs and Years:

No. To align with HPA, NCQA does not review communication to practitioners about the availability of UM criteria in UM 4, Element B in UM Accreditation or BHA. Instead, NCQA evaluates whether the organization makes the criteria available electronically (e.g., through an EHR, portal, or website). Acceptable evidence includes system reports or screenshots demonstrating how practitioners access the criteria at the point of care.

Applicable standards:

• Utilization Management Accreditation – UM 4, Element B
• Behavioral Health Accreditation – UM 2, Element B

This applies to the following Programs and Years:

For PHM 2, Element B, factor 4 the organization must assess the needs of members with serious mental illness (SMI) and assess the needs of members with serious emotional disturbance (SED). If a member has both conditions, separate assessments are not required under factor 4. The organization determines if the member is assessed as a member with SMI or SED.

Applicable standards: 
•    Health Plan Accreditation – PHM 2, Element B
•    Behavioral Health Accreditation – PHM 2, Element B

This applies to the following Programs and Years:

If delegates that render medical necessity determinations do not have access to, manage, or handle UM request receipt dates or UM decision notification dates for any client—and no receipt or notification dates are stored in the delegates’ systems—then UM 12, Element C, factors 5–7 may be scored Not Applicable (NA), because the intent of these factors is to evaluate the integrity of receipt and notification dates.

If an organization retains sole responsibility for receiving UM requests, documenting receipt dates, and issuing UM decision notifications—and its delegates render medical necessity determinations only—then UM 12, Element C, factors 5–7 do not apply to those delegates.

Applicable standards:

• Health Plan Accreditation: UM 12, Element C
• Behavioral Health Accreditation: UM 11, Element C
• Utilization Management Accreditation: UM 8, Element C

This applies to the following Programs and Years:

No. For NCQA Health Plan Accreditation, NCQA reviews and scores UM 1, Elements B–H separately for each product line brought forward for Accreditation. Organizations may not combine any product lines—including commercial and Exchange—when reporting and evaluating UM rates for UM 1, Elements B–H.

Applicable standards: 

• Health Plan Accreditation: UM 1, Elements B-H.  
• Behavioral Health Accreditation: UM 1, Elements B-F. 
• Utilization Management Accreditation: UM 3, Elements B-H. 

This applies to the following Programs and Years:

UM Information Integrity oversight requirements related to UM request receipt and UM decision notification dates may be scored Not Applicable (NA) for delegates that only perform approvals and/or recommendations. Please note that this exception does not apply to delegates that make denial decisions.
Factors 5–7 are limited to the evaluation of UM receipt and notification dates.

Applicable standards:

• Health Plan Accreditation: UM 12, Element C, factors 5–7
• Utilization Management Accreditation: UM 8, Element C, factors 5–7
• Behavioral Health Accreditation: UM 10, Element C, factors 5–7

This applies to the following Programs and Years:

No. Organizations must use 12 months of continuous data and may use data from the most recent calendar year (e.g., January 1–December 31). The workbook must be completed at least once during the look-back period. 

Applicable standards: 

• Health Plan Accreditation: UM 1, Elements B-H.  
• Behavioral Health Accreditation: UM 1, Elements B-F. 
• Utilization Management Accreditation: UM 3, Elements B-H.

This applies to the following Programs and Years: