FAQ Directory: Health Plan Accreditation

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.

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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.

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• Use the NCQA Health Plan Accreditation standards to perform a gap analysis and determine improvement areas. They provide a framework for implementing evidence-based, best practices help plans improve in areas of:
  • QI process.
  • Population health management.
  • Practitioner network and access to care.
  • Utilization management processes.
  • Credentialing and recredentialing processes.
  • Members’ rights and responsibilities.
  • Member connection.
  • Medicaid service requirements.
• Satisfy state requirements and employer needs. The standards align with many state requirements.

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Earning NCQA Accreditation of Case Management for LTSS can help organizations:

• Become more efficient. A focus on coordinated care, training and measurement can help organizations reduce errors and duplicated services.
• Integrate care better. Standards can help organizations improve communication between individuals, caregivers, providers, payers and other organizations that coordinate care.
• Provide person-centered care. Standards focus on person-centered services, which can lead to better care planning and monitoring.
• Support contracting needs. Standards align with the state needs. NCQA-Accredited organizations demonstrate that they’re ready to be trusted partners in coordinating LTSS services.

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Meeting NCQA Medicaid Module standards can help organizations:

• Streamline compliance activities. Compliance activities are reduced when the state uses NCQA Health Plan Accreditation and Medicaid Module standards as part of the Medicaid quality review.
• Become more efficient. Reallocate key quality review resources to other Medicaid priorities.

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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.

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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.

HP 2020

The first step to earning distinction 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 distinction status within 30 days of the final review.

See a step-by-step process.

HP 2020

• LTSS Best Practices Academy: Interactive forum for professionals to discuss strategies for coordinating quality long-term services and supports (LTSS) programs.
• LTSS Roadmap: A compilation of resources to guide organizations through meeting Case Management and Health Plan Standards for LTSS.

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Any organization that provides managed health care services may apply for the NCQA Health Plan Accreditation if it meets the following criteria:

• Operates under an insurance license (e.g., HMO, POS, PPO, EPO), and
• Issues a contract for insurance for a defined population or contracts with an employer to provide managed care services for a self-insured population, and
• Provides services through an organized delivery system that includes ambulatory and inpatient health care sites, and
• Performs functions addressed in the standards (quality improvement, care coordination, utilization management, credentialing, member rights and responsibilities), either directly or through a service agreement, and
• Has a process for monitoring, evaluating and improving the quality and safety of care provided to its members, and
• Reports audited HEDIS results for designated HEDIS measures and CAHPS ratings and composites, as required for the selected Evaluation Option.

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NCQA standards are a roadmap for improvement—organizations use them to perform a gap analysis and align improvement activities with areas that are most important to states and employers, such as network adequacy and consumer protection. Standards help plans in:

• Quality Management and Improvement.
• Population Health Management.
• Network Management.
• Utilization Management.
• Credentialing and Recredentialing.
• Members’ Rights and Responsibilities.
• Member Connections.
• Medicaid Benefits and Services.

HP 2020

An organization is eligible for the NCQA Health Plan Medicaid Module if:

• Its Medicaid product line has a current NCQA Accreditation status as a First or Renewal Survey, or
• It is seeking accreditation for its Medicaid product line under NCQA HP Accreditation as an Interim, First or Renewal Survey.

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