FAQ Directory: Utilization Management, Credentialing and Provider Network

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

8.24.2018 Where can I find the Provider Network Standards and Guidelines?

Find the Standards and Guidelines document in the NCQA eStore.

UM_CR 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.

UM_CR 2019

8.24.2018 What is the price for Provider Network Accreditation?

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

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 How do I get started with Utilization Management 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 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 does Provider Network Accreditation help my organization?

Use the NCQA Provider Network Accreditation standards to perform a gap analysis and determine improvement areas. The standards provide a framework for implementing industry best practices to:

Improve operational efficiencies.
- Consistent monitoring of practitioner availability and accessibility of services.
- Efficient collection and analysis of member-experience data.
- Appropriate credentialing of practitioners and providers.
Elevate your organization’s reputation. Accreditation demonstrates that your organization has the processes and procedures to provide effective network management services.
Align with state requirements. Use accreditation standards to improve your internal operations and align with state requirements.
Improve contracting opportunities. Ability to reduce administrative responsibility for NCQA-Accredited organizations that delegate network management and credentialing activities.

UM_CR 2019

8.23.2018 What organizations are eligible for Credentialing Accreditation?

Credentialing Accreditation is for organizations that provide full scope credentialing 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 credentialing functions directly or through a contract.
Must perform credentialing activities for at least 50% of a practitioner network.

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

UM_CR 2016

8.23.2018 What are the Credentialing Accreditation requirements?

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

Internal Quality Improvement Process
Agreement and Collaboration With Clients
Protecting Credentialing Information
Credentialing Policies
Credentialing Committee
Credentialing Verification

Recredentialing Cycle Length
Ongoing Monitoring
Notification to Authorities and Practitioner Appeal
Rights
Assessment of Organizational Providers
Delegation of CR

UM_CR 2016

8.23.2018 Where can I find information to help me get started with Credentialing 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 2016

8.23.2018 How long does it take to earn Credentialing 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 2016