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Utilization Management Accreditation Requirements

NCQA Utilization Management Accreditation evaluates organizations performing full-scope utilization management services. Organizations must meet program criteria to pursue this accreditation.

Focus areas to ensure high quality

NCQA Utilization Management Accreditation is designed to ensure that organizations can consistently make appropriate and timely decisions. Requirements cover these key areas:

  • Applying an internal QI process.
  • Appropriate client agreements and collaboration.
  • Member confidentiality.
  • Using appropriate professionals.
  • Making fair and timely decisions.
  • Handling member appeals.

To see all program requirements, get the Standards and Guidelines document.

Required organization services

The standards are designed for organizations providing full-scope utilization management services that include the use of evidence-based criteria, relevant clinical information and qualified health professionals to make utilization management decisions.

Is my organization eligible?

NCQA Utilization Management Accreditation is for organizations that provide full-scope utilization management services. Eligible organizations:

  • Must not be licensed as an HMO, POS, PPO or EPO.
  • Must not be eligible for NCQA Accreditation as a health plan or an MBHO.
  • Must perform utilization management functions directly or through a contract.
  • Must perform utilization management activities for at least 50% of the members.

Note: “Members” refers to membership of clients and organizations.

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