Utilization Management Accreditation FAQs

What is 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.

*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.

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.

What are the Utilization Management Accreditation requirements?

NCQA 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 and Guidelines document.

Where can I find the Standards and Guidelines?

Find the Standards and Guidelines document in the NCQA Store.

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.

*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.

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.

See a step-by-step process.

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.

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.

How do I get started?

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 .

Where can I find information to help me get started?

• Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation.
• Standards and Guidelines: The complete standards and guidelines, including the intent statement 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.

What other organizations have earned Utilization Management Accreditation?

More than 50 organizations have earned NCQA Utilization Management Accreditation. See the NCQA Report Card for a directory of accredited organizations.