FAQ Directory: Utilization Management, Credentialing and Provider Network

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9.15.2018 Revised Look-back Period for UM 7, Elements C, F, I (factors 2 and 3) In the 2019 HPA Standards and Guidelines, NCQA added a fifth bullet to the factor 2 Explanation and revised the factor 3 Explanation in UM 7, Elements C, F and I. Will NCQA give organizations a grace period for the added information in factors 2 and 3 of UM 7, Elements C, F and I?

The intent of the added language in factors 2 and 3 was to clarify the minimum information required for expedited appeals. NCQA recognizes these are new requirements, and for this reason, has added the following language to the scope of review:

Organizations must implement the changes in factors 2 and 3 for files processed on or after 11/1/18.

NCQA will post an update in December for the 2019 HP publication to reflect this change.

This applies to the following Programs and Years:
HP 2019|UM-CR-PN 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.

This applies to the following Programs and Years:
UM-CR-PN 2018, 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.

This applies to the following Programs and Years:
UM-CR-PN 2018, 2019

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

Find the Standards and Guidelines document in the NCQA eStore.

This applies to the following Programs and Years:
UM-CR 2017|UM-CR-PN 2018, 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.

This applies to the following Programs and Years:
UM-CR-PN 2018, 2019

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.

This applies to the following Programs and Years:
UM-CR 2017|UM-CR-PN 2018, 2019

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

This applies to the following Programs and Years:
UM-CR 2017|UM-CR-PN 2018, 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.
 

This applies to the following Programs and Years:
UM-CR 2017|UM-CR-PN 2018, 2019

8.24.2018 What is the price for Utilization Management Accreditation?

Pricing is based on multiple factors. Obtain full pricing information by submitting a request through My NCQA.

This applies to the following Programs and Years:
UM-CR 2017|UM-CR-PN 2018, 2019

8.24.2018 What is the process for earning Provider Network Accreditation?

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 Provider Network standards. NCQA conducts the survey and determines your accreditation status within 30 days of the final review.

 

  See a step-by-step process.

This applies to the following Programs and Years:
UM-CR-PN 2018, 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.

This applies to the following Programs and Years:
UM-CR-PN 2018, 2019

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

This applies to the following Programs and Years:
UM-CR-PN 2018, 2019