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FAQ Directory: Utilization Management, Credentialing and Provider Network

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8.24.2018 What is Utilization Management Accreditation?

NCQA Utilization Management Accreditation is a comprehensive program that evaluates the operations of organizations providing full-scope utilization management services, which include using evidence-based criteria, relevant clinical information and qualified health professionals to make utilization management decisions.

UM_CR 2013

8.24.2018 Where can I find the Provider Network Standards and Guidelines?

8.24.2018 What are the Utilization Management Accreditation requirements?

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 & Guidelines document.
 

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

8.24.2018 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.

UM_CR 2019

8.24.2018 What is the price for Provider Network Accreditation?

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

UM_CR 2019

8.24.2018 How do I get started with Utilization Management Accreditation?

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 My NCQA.

UM_CR 2019

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 How long does it take to earn Credentialing 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 2016

8.23.2018 How do I get started with Credentialing Accreditation?

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 My NCQA.

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 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