Provider Network Accreditation Requirements

FOCUS AREAS TO ENSURE HIGH QUALITY

Provider Network Accreditation requirements ensure that organizations can provide efficient, accurate and consistent network management and credentialing services. Requirements cover these key areas:

• Credentialing and recredentialing:
  • Protecting information.
  • Verifying credentials.
  • Ongoing monitoring of sanctions and complaints.
• Network management:
  • Maintaining adequate network.
  • Providing access to appointments.
  • Continuity and coordination of care.
  • Providing directory information.

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

REQUIRED ORGANIZATION SERVICES

The standards are designed for organizations providing full-scope credentialing and network management services to employers, regulatory agencies, health plans and MBHOs. These services include monitoring practitioner availability, managing member access to services, tracking member experience data and credentialing and recredentialing practitioners.

IS MY ORGANIZATION ELIGIBLE?

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.

*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.

PROVIDER NETWORK SUPPORT

Find information about NCQA Provider Network Accreditation here:

• 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.
• Policy Updates: Lists corrections, clarifications and policy changes to our stated Standards and Guidelines.
• Education and Training: NCQA offers a variety of training options, from on-demand web-based programs to live in-person seminars.
• Advertising Guidelines: Designed to help customers create clear, factual and accurate advertising and marketing materials.
• Seals: Created to provide print-friendly graphics for use in promoting the NCQA status.