Credentialing Accreditation Requirements

FOCUS AREAS TO ENSURE HIGH QUALITY

NCQA Credentialing Accreditation is designed to ensure that organizations can maintain a high-quality network for members and contracted clients. Requirements cover these key areas:

• An internal QI process.
• Ensuring appropriate agreements and collaboration with clients.
• Protecting credentialing information.
• A peer-review process.
• Credential verification.
• Monitoring of sanctions and complaints.

To see all program requirements, get the Standards & Guidelines document.

REQUIRED ORGANIZATION SERVICES

The standards are designed for organizations that provide full-scope credentialing services, including:

• Verification of practitioner credentials through a primary source, through a recognized source or through a contracted agent of the primary source.
• A designated credentialing committee that reviews practitioner credentials and makes credentialing recommendations.
• Monitoring practitioner sanctions, complaints and quality issues between recredentialing cycles.

IS MY ORGANIZATION ELIGIBILE?

Organizations eligible for Credentialing Accreditation:

• 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 contractual agreement.
• Must perform credentialing activities for at least 50% of the practitioner network.

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

* NCQA-Accredited health plans or MBHOs are eligible for Accreditation in UM, CR or PN if they also maintain health plan or MBHO Accreditation. If an organization allows its Accreditation status to lapse, its UM, CR or PN Accreditation status will remain in place but may not be renewed.