FAQ Directory: Utilization Management, Credentialing and Provider Network

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8.24.2018 Where can I find information to help me get started with Provider Network Accreditation?

Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation.
Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review.
Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organization’s survey readiness—the tool calculates your potential survey score.

UM_CR 2019

8.24.2018 How do I get started with Provider Network 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.

UM_CR 2019

8.24.2018 What other organizations have earned Utilization Management Accreditation?

More than 50 organizations have earned NCQA Utilization Management Accreditation. See the NCQA Report Card for a directory of accredited organizations.

UM_CR

8.24.2018 Where can I find the Utilization Management Standards and Guidelines?

Find the Standards and Guidelines document in the NCQA eStore.

UM_CR 2019

8.24.2018 What organizations are eligible for Provider Network Accreditation?

To be eligible for Provider Network Accreditation, an organization must:

Not be licensed as an HMO, POS, PPO or EPO.
Not be eligible for NCQA Accreditation as a health plan or an MBHO.
Perform Provider Network functions directly or through contractual agreement.
Perform Provider Network activities for at least 50% of the provider network.

Note: A “practitioner network” is the practitioner network of clients and organizations.

UM_CR 2019

8.24.2018 Where can I find information to help me get started with Utilization Management Accreditation?

Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation.
Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review.
Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organization’s survey readiness—the tool calculates your potential survey score.

UM_CR 2019

8.24.2018 What are the Utilization Management Accreditation requirements?

Utilization Management Accreditation assesses an organization’s performance in the following areas:

Improving operations through an internal QI process
Ensuring appropriate agreements and collaboration with clients
Maintaining member confidentiality
Ensuring involvement of appropriate professionals
Making fair and timely decisions
Handling member appeals in a fair and timely manner
Measuring member and provider experience

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

UM_CR 2019

8.24.2018 What are the Provider Network Accreditation requirements?

Provider Network Accreditation assesses an organization’s performance in the following key areas:

Credentialing and recredentialing	Network management
Protecting information	Maintaining adequate network
Verifying credentials	Providing access to appointments
Ongoing monitoring of sanctions and complaints	Continuity and coordination of care
	Providing directory information

UM_CR 2019

8.24.2018 How does Utilization Management Accreditation help my organization?

NCQA Utilization Management Accreditation is designed to ensure that organizations pursuing accreditation can deliver fair and timely determinations to get the proper care to patients while effectively managing resources. The standards provide a framework for adopting industry best practices to objectively and efficiently evaluate the appropriateness of requested health care services.

UM_CR 2013

8.24.2018 What is Utilization Management Accreditation?

NCQA Utilization Management Accreditation is a comprehensive program that evaluates the operations of organizations providing full-scope utilization management services, which include using evidence-based criteria, relevant clinical information and qualified health professionals to make utilization management decisions.

UM_CR 2013

8.24.2018 What is Provider Network Accreditation?

NCQA Provider Network Accreditation is a comprehensive, evidence-based program dedicated to quality improvement that evaluates the accessibility and transparency of organization networks and credentialing of practitioners and providers. NCQA-Accredited organizations demonstrate they have the internal processes and procedures to effectively manage access to care and member experience while ensuring that practitioners and providers are appropriately credentialed.

UM_CR 2019

8.24.2018 What other organizations have earned Provider Network Accreditation?

Several organizations have earned NCQA Provider Network Accreditation. See the NCQA Report Card for a directory of accredited organizations.

UM_CR 2019