FAQ Directory: Utilization Management, Credentialing and Provider Network

• 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.

• 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.
 

• 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.

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.

• 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.

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.