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 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 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 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

8.23.2018 What is the price for Credentialing Accreditation?

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

UM_CR 2016

8.23.2018 Where can I find the Standards and Guidelines?

Find the Standards and Guidelines document in the NCQA eStore.

UM_CR 2016

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 How does Credentialing Accreditation help my organization?

NCQA Credentialing Accreditation is designed to ensure that organizations pursuing accreditation can maintain a high-quality network for members and contracted clients. The standards provide a framework for adopting industry best practices to accurately and efficiently credential and recredential health care professionals—ensuring that medical organizations employ qualified professionals and align with state requirements.

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 What is Credentialing Accreditation?

NCQA Credentialing Accreditation is a comprehensive program that evaluates the operations of organizations providing full-scope credentialing services, which include verifying practitioner credentials, designated credentialing-committee review of practitioners and monitoring practitioner sanctions.

UM_CR 2016

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

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 What other organizations have earned Credentialing Accreditation?

More than 90 organizations have earned NCQA Credentialing Accreditation. See the NCQA Report Card for a directory of accredited organizations.

UM_CR 2016