FAQ Directory: Utilization Management, Credentialing and Provider Network

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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 Where can I find the Utilization Management Standards and Guidelines?

8.24.2018 What organizations are eligible for Utilization Management Accreditation?

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.

UM_CR 2019

8.24.2018 How long does it take to earn Utilization Management Accreditation?

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.

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 information to help me get started with Utilization Management Accreditation?

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

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

8.24.2018 How long does it take to earn Provider Network Accreditation?

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.

UM_CR 2019