FAQ Directory: Utilization Management, Credentialing and Provider Network

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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.

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 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 the Provider Network Standards and Guidelines?

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 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 What is the process for earning Utilization Management 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 utilization management standards. NCQA conducts the survey and determines your accreditation status within 30 days of the final review.

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

8.23.2018 What is the process for earning Credentialing 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 CR standards. NCQA conducts the survey and determines your accreditation status within 30 days of the final review.

See a step-by-step process.

UM_CR 2016