NCQA

Glossary

Use the glossary to learn more about different NCQA programs and what each status means.

CM - Case Management Accreditation

Case Management (CM) Accreditation: This program accredits organizations that manage patients who have complex needs. It.is a comprehensive, evidence-based accreditation program dedicated to quality improvement that can be used for case management programs in provider, payer or community-based organizations.
  • Date of Next Review: The next scheduled survey start date. Accreditation status is determined approximately 90 days after the survey start date.
  • Evaluation Product: Accreditation
  • Expiration: Date that accreditation is no longer valid.
  • Status: Organization's accreditation standing based upon level of performance.
    • Accredited-3 years: NCQA awards a status of Accredited – 3 years to organizations that demonstrate strong performance of the functions outlined in the standards for CM accreditation.
    • Accredited-2 years: NCQA awards a status of Accredited – 2 years to organizations that demonstrate performance of the functions outlined in the standards for CM accreditation.
    • Denied: NCQA denies Accreditation to organizations that did not meet NCQA requirements during the Accreditation Survey.
    • LTSS Distinction – NCQA awards LTSS Distinction to organizations that deliver efficient, effective person-centered care that meets people′s needs, helps keep people in their preferred setting and aligns with state requirements.

CR - Credentialing

Credentialing (CR):This program assesses organizations that verify practitioners′ credentials, monitor practitioner sanctions, complaints and quality issues between recredentialing cycles, and assess organizational providers.
  • Date of Next Review: The next scheduled survey start date. Accreditation status is determined approximately 90 days after the survey start date.
  • Evaluation Product: Accreditation
  • Expiration: Date that accreditation is no longer valid.
  • Status: Organization's certification standing based upon level of performance.
    • Accredited: The organization's program meets or exceeds NCQA standards for Utilization Management.
    • Denied: The organization's program does not meet NCQA standards for Utilization Management.
    • Under Discretionary Review: NCQA is reviewing an organization to assess the appropriateness of an existing accreditation decision
    • Under Review: The organization's accreditation status is under review at its request.

CM-LTSS - Case Management - Long-Term Services and Supports

Case Management-Long-Term Services and Supports (CM-LTSS): This program evaluates organizations that plan and manage personalized care and services for people experiencing difficulty completing self-care tasks as a result of aging, chronic illness or disability. These organizations should create a person-driven support system to help people live independently and stay in their homes.
  • Date of Next Review: The next scheduled survey start date. Accreditation status is determined approximately 90 days after the survey start date.
  • Evaluation Product: Accreditation, Distinction
  • Expiration: Date that accreditation or distinction is no longer valid.
  • Status: Organization's accreditation or distinction standing based upon level of performance.
    • Accredited-3 years: NCQA awards a status of Accredited – 3 years to organizations that demonstrate strong performance of the functions outlined in the standards for CM-LTSS accreditation.
    • Accredited-2 years: NCQA awards a status of Accredited – 2 years to organizations that demonstrate performance of the functions outlined in the standards for CM-LTSS accreditation.
    • Denied: NCQA denies Accreditation to organizations that did not meet NCQA requirements during the Accreditation Survey
    • Distinction: NCQA awards CM-LTSS Distinction to NCQA-Accredited health plans and Managed Behavioral Healthcare Organizations who demonstrate their ability to effectively coordinate LTSS in addition to physical and behavioral health services.

CVO - Credentials Verification Organizations

Credentials Verification Organization (CVO) Certification: This program evaluates credentials verification organizations and the processes that they use to continuously improve services for managed care clients. CVO certification is available to organizations that conduct credentials verification, report credentialing information to clients and have systems in place to protect confidentiality and integrity of the information.
  • Evaluation Product: Certification
    • Certification in Verification of Licensure: The organization uses NCQA-approved sources to verify practitioner licensure.
    • Certification in DEA: The organization uses NCQA-approved sources to verify practitioner DEA or CDS certification.
    • Certification in Education and Training: The organization use NCQA-approved sources to verify practitioner education and training.
    • Certification in Verification of Board Certification Status: The organization uses NCQA-approved sources to verify practitioner board certification status.
    • Certification in Work History: The organization uses NCQA-approved sources to verify practitioner work history.
    • Certification in Malpractice Claims History: The organization uses NCQA-approved sources to verify practitioner malpractice claims history.
    • Certification in Medical Board Sanctions: The organization use NCQA-approved sources to verify practitioner medical board sanctions.
    • Certification in Medicare/Medicaid Sanctions: The organization use NCQA-approved sources to verify practitioner Medicare/Medicaid sanctions.
    • Certification in Application and Attestation Processing: The organization processes applications according to NCQA requirements.
    • Certification in Application and Attestation Content: The organization's application meets NCQA requirements.
    • Certification in Ongoing Monitoring of Sanctions: The organization has policies and procedures for ongoing monitoring of practitioner sanctions between recredentialing cycles.
  • Status: Organization's certification standing based upon level of performance.
    • Certified: NCQA awards certification to an organization that demonstrates, in NCQA's judgment, substantial performance against the requirements within core standards and chosen certification options.
    • Denied: A denied status occurs when, in NCQA's judgment, the organization fails significantly to comply with the requirements within core standards and chosen certification options of the CVO program.

DAV - Data Aggregator Validation

Data Aggregator Validation (DAV): This program evaluates clinical data streams to help ensure that health plans, providers, government organizations and others can trust the accuracy of aggregated clinical data.
  • Evaluation Product:
    • Validated Data Stream: The organization listed is the accountable entity for a data stream that was validated through the Data Aggregator Validation program. To learn what data streams are validated, contact the accountable organization.
    • Certified Data Partner: The organization listed earned certification in one or more standards areas. A certified data partner has shown they demonstrate capabilities to support data stream validation and findings from the certification may be portable, saving partners time in validating data streams. Findings for certified data partners are only applicable when supporting a responsible party to validate a data stream. Their findings do not stand alone for use elsewhere.
  • Status:
    • Validated Data Stream: Has gone through the validation process and a data stream earned validation.
    • Certified Data Partner: Has gone through the process as a certified data partner and the organization earned.
  • Next Review Date: The date one year from the last date of validation/certification. Organizations must get revalidated/recertified prior to this date to maintain their status.

DRP - Diabetes Recognition Program

Diabetes Recognition Program (DRP): This program evaluates practices and clinicians that use evidence-based measures to provide excellent care to their patients with diabetes. Those who achieve DRP Recognition show that they are part of an elite group that is publicly recognized for their skill in providing the highest-level diabetes care.
  • Clinician: The clinicians listed have earned this recognition.
  • Clinician Recognition: Clinician has demonstrated that they meet or exceed NCQA Standards for providing high-quality care to patients with diabetes.
  • Dates: Period for which Recognition is valid.
  • Practice: The location where clinician or practice has earned recognition.
  • Practice Recognition: Practice has demonstrated that it meets or exceeds NCQA Standards for providing high-quality care to patients with diabetes.

Electronic Clinical Data

Electronic Clinical Data Distinction: NCQA is discontinuing the Electronic Clinical Data Distinction. The Measurement Year 2022 reporting year was the final year for organizations to earn the Distinction. Plans were required to report a non-zero rate for at least one non-publicly reported ECDS measure for the applicable measurement year. As of Measurement Year 2023, all but one ECDS measure (SNS-E) were publicly reported. Earning Distinction for one measure does not meet the original intent, however, NCQA continues to encourage organizations to leverage electronic clinical data and to report these more challenging measures.
For more information, please visit: www.ncqa.org/ecds.

HE - Health Equity Accreditation

Health Equity Accreditation: This program evaluates how well an organization establishes a standardized framework for turning health equity into a culture of continuous improvement. The standards include building an internal culture that supports diversity, equity, and inclusion, collecting data to understand the demographics of the population, offering language services and provider networks mindful of individuals’ cultural and linguistic needs and identifying opportunities to reduce health inequities and improve care.
  • Evaluation Product: Accreditation
  • Expiration: Date that accreditation is no longer valid.
  • Status: Organization's accreditation standing based upon level of performance.
    • Accredited: Service and quality meet rigorous requirements for the delivery of culturally appropriate care and quality improvement interventions serving diverse populations.
    • Provisional: Service and quality meet some requirements; improvement is needed to achieve higher status.
    • Denied: Did not meet NCQA requirements.
    • Expired: Previously accredited, has chosen not to renew.

HE Plus - Health Equity Accreditation Plus

Health Equity Accreditation Plus: This program is for organizations further along on their health equity journey. The standards evaluate how the organization is collecting data on social risk factors and social needs, establishing partnerships that support community-based organization, engaging consumers, individual members, and community stakeholders in program evaluation, and referring individuals to social resources that will have the most impact.
  • Evaluation Product: Accreditation
  • Expiration: Date that accreditation is no longer valid.
  • Status: Organization's accreditation standing based upon level of performance.
    • Accredited: Service and quality meet rigorous requirements for mitigating the social drivers of health inequities and delivering interventions responsive to the needs of the populations served.
    • Provisional: Service and quality meet some requirements; improvement is needed to achieve higher status.
    • Denied: Did not meet NCQA requirements.
    • Expired: Previously accredited, has chosen not to renew.

HIP - Health Information Products

Health Information Product (HIP) Certification: This program evaluates organizations that provide pharmacy benefit information, health information lines, support for healthy living or physician and hospital directories services to health plans and Managed Behavioral Health Organizations.
  • Date of Next Review: The next scheduled survey start date. Accreditation status is determined approximately 90 days after the survey start date.
  • Evaluation Product: Certification. An organization may seek certification in any or all of the following evaluation options:
    • Health Information Line: The organization has a health information line to assist eligible individuals with wellness and prevention.
    • Support for Healthy Living: The organization provides access to wellness and prevention services.
    • Pharmacy Benefit Information: The organization provides eligible individuals with the information they need to understand and use their pharmacy benefits.
    • Physician and Hospital Directories: The organization provides information to help eligible individuals choose physicians and hospitals.
  • Expiration: Date that accreditation or certification is no longer valid.
  • Status: Organization's certification standing based upon level of performance.
    • Certified: The organization's tools and services meet or exceed NCQA standards for Health Information Product.
    • Denied: The organization's tools and services do not meet NCQA requirements.

HPA - Health Plan Accreditation

Health Plan Accreditation (HPA): This program evaluates:
  • Accreditation: Accreditation is a detailed review of how well health care organizations meet their patients' needs. Many people, including employers, government officials and health insurance industry leaders, regard NCQA's review as the gold standard for checking health care quality. Some health insurance plans volunteer to be Accredited. Others sign up because state governments require the review. Read more about Accreditation here.
  • Accreditation Type: NCQA Accreditation uses a common set of standards and guidelines for all product lines (i.e., commercial, Medicare, Medicaid and Exchange) and products (HMO, POS, PPO and EPO).
  • CAHPS®: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a series of surveys that patients use to rate their health care experiences. The Agency for Healthcare Research and Quality (AHRQ) sponsors the surveys, which ask patients and family members about different aspects of their care, such as communication with their doctor and pain management.
  • HEDIS®: HEDIS (Healthcare Effectiveness Data and Information Set) is a tool used by over 90% of America's health plans to measure performance on care and services. It is also the most widely used performance improvement tool in health care. HEDIS has more than 90 measures that address different areas of care, such as asthma medication use and controlling high blood pressure. View more information about HEDIS.
  • Measure: A tool used to evaluate health care activities, clinical outcomes and patient perceptions.
  • Accreditation Status and Status Modifiers: Organization's Accreditation standing based upon level of performance.
    • Accredited: Service and quality meet or exceed rigorous requirements for consumer protection and quality improvement.
    • Provisional: Service and quality meet some requirements; improvement is needed to achieve higher status.
    • Interim: Basic structure and processes in place to meet expectations for organizations new to NCQA.
    • Denied: Did not meet NCQA requirements.
    • Appealed by Organization: The health plan asked the Accreditation status to be reviewed.
    • In Process: NCQA is deciding Accreditation status.
    • Revoked: NCQA removed Accreditation.
    • Scheduled: On calendar for an Accreditation survey.
    • Expired: Previously Accredited, has chosen not to renew.
    • Under Review by NCQA: NCQA is confirming if performance is at the level required for Accreditation.
    • Merger Review in Process: NCQA is analyzing merger's impact on Accreditation status.
    • Under Corrective Action: A CAP Survey is required when an organization does not meet the minimum threshold for one or more must-pass elements. The organization's Accreditation status on the Report Cards is noted with an “Under Corrective Action” status modifier during the corrective action period.
      NCQA proactively schedules the CAP Survey for submission 6 months following the last Full Survey, with the file review or survey end date 4 weeks later.
  • Standard: A basis for comparison or a reference point for evaluating a health plan. NCQA standards define acceptable performance.
  • LTSS Distinction: NCQA awards LTSS Distinction to organizations that deliver efficient, effective person-centered care that meets people′s needs, helps keep people in their preferred setting and aligns with state requirements.

HPR - Health Plan Ratings

Health Plan Ratings (HPR): NCQA's annual Health Plan Ratings includes results for both Accredited and non-Accredited commercial, Medicare and Medicaid health plans. The overall rating (0-5, in 0.5 increments) is the weighted average of a plan’s HEDIS® and CAHPS® measure ratings, plus bonus points for plans with Accredited, Provisional and Interim status as of the last business day in June of the release year. For more information, please visit: https://www.ncqa.org/hedis/health-plan-ratings/.
  • CMS Contract: CMS contract numbers are a four-digit number preceded by “H,” or “R.” This variable is the unique identification for a managed care organization (MCO) enabling the entity to provide coverage to eligible Medicare beneficiaries. Local managed care contracts begin with H or 9 and regional managed care contracts begin with R.
  • Special Area: Used to distinguish between multiple submissions with the same product line, reporting product, which cover different regions. If only one submission is requested, the default is None, unless the submission is for the SNP project. For SNP submissions, this is the CMS plan ID.
  • Special Project: Used to distinguish between multiple submissions with the same product line, reporting product, for different state or federal agency requirements. If only one submission is requested, the default is None, unless the submission is for the SNP project.

HSRP - Heart/Stroke Recognition Program

Heart/Stroke Recognition Program (HSRP): This program evaluates practices and clinicians that use evidence-based measures to provide excellent care to their patients with heart and/or vascular disease. Those who achieve HSRP Recognition show that they are part of an elite group that is publicly recognized for their skill in providing the highest-level heart and/or vascular disease care.
  • Clinician: The clinicians listed have earned this recognition.
  • Clinician Recognition: Clinician has demonstrated they meet or exceed NCQA Standards for providing high-quality care to patients with heart or vascular disease.
  • Dates: Period for which Recognition is valid.
  • Practice: The location where clinician or practice has earned recognition.
  • Practice Recognition: Practice has demonstrated that it meets or exceeds NCQA Standards for providing high-quality care to patients with heart or vascular disease.

MBHO - Managed Behavioral Healthcare Organizations

Managed Behavioral Healthcare Organizations (MBHO): This program evaluates whether organizations improve the quality and safety of care provided to members; coordinate medical and behavioral healthcare; meet standards for access and services; and review and verify the credentials of the practitioners in their network.
  • Date of Next Review: The next scheduled survey start date. Accreditation status is determined approximately 90 days after the survey start date.
  • Distinction: Special acknowledgement of achievement in defined categories of providing patient services.
  • Expiration: Date that accreditation is no longer valid.
  • Evaluation Product: Accreditation
    • MBHO Accreditation: This program evaluates whether organizations improve the quality and safety of care provided to members; coordinate medical and behavioral healthcare; meet standards for access and services; and review and verify the credentials of the practitioners in their network.
  • Insurance Type: A plan (Commercial, Medicare, Medicaid, Health Insurance Exchange) designed to provide health care coverage to a specific population or group of people.
    • Commercial: Health care coverage paid for by employers or individual consumers.
    • Medicare: The federal government's health care program for people 65 and older and for younger people who have disabilities and cannot work.
    • Medicaid: A federally required, state-funded health care program for low-income or disabled people.
    • Health Insurance Exchange: Government-regulated and standardized health insurance plans.
  • Status: Organization's accreditation standing based upon level of performance.
    • Full: The organization's quality improvement and consumer protection programs meet or exceed NCQA standards.
    • One-Year: The organization's quality improvement and consumer protection programs are well established and meet most NCQA standards. NCQA gives the organization a list of recommendations and within 15 months reviews the organization again to determine if it qualifies for Full Accreditation.
    • Provisional: An organization's programs for quality improvement and consumer protection are adequate and meet some NCQA standards. NCQA gives the organization a list of recommendations and within 15 months performs another review to determine if it qualifies for a higher level of accreditation.
    • Denied: Did not meet NCQA requirements.
    • LTSS Distinction – NCQA awards LTSS Distinction to organizations that deliver efficient, effective person-centered care that meets people′s needs, helps keep people in their preferred setting and aligns with state requirements.

MHC - Multicultural Health Care

Multicultural Health Care: This program offers distinction to organizations that engage in efforts to improve culturally and linguistically appropriate services and reduce health care disparities. It evaluates organizations, such as health plans, wellness, disease management and managed behavioral health organizations through use of an evidence-based set of requirements.
  • Evaluation Product: Distinction
  • Expiration: Date that distinction is no longer valid.
  • Status: Organization's distinction standing based upon level of performance.
    • Distinction: NCQA awards the status of Distinction to organizations that meet or exceed its standards for Distinction in Multicultural Health Care.
    • Denied: NCQA awards the status of Denied to organizations that do not meet its Distinction in Multicultural Health Care requirements during the survey.

NYS PCMH – New York State Patient-Centered Medical Home Recognition Program

New York State Patient-Centered Medical Home Recognition Program (NYS PCMH): The New York State Patient-Centered Medical Home (NYS PCMH) Recognition Program is an exclusive model of the NCQA PCMH program developed in collaboration with NYS DOH that supports the state′s initiative to improve primary care and promote the Triple Aim: better health, lower costs and better patient experience. This program evaluates primary care practices that use teamwork and technology to deliver comprehensive and coordinated patient-centered primary care.
  • Anniversary Date: The date which a recognition will lapse if a practice does not take additional action with NCQA.
  • Clinician: The clinicians listed within a practice that has earned PCMH Recognition.
  • Dates: Period for which recognition is valid.
  • Distinctions: Special acknowledgement of achievement in defined categories of providing patient-centered care.
  • Patient Experience: This distinction acknowledges practices that survey patients for satisfaction with the Medical Home version of the CAHPS Clinician and Group Survey. Practices can earn distinction for collecting data through a certified vendor using the standardized survey, following the defined methods and reporting the results to NCQA.
  • Practice: The practice where recognition was earned.

Patient-Centered Connected Care Recognition Program

Patient-Centered Connected Care Recognition Program: This program evaluates organizations that deliver evidence-based, clinically appropriate care while promoting enhanced connections and value-add interactions between medical homes and other providers. The organizations also demonstrate a commitment to supporting the medical home as the hub of patient information, primary care provision and care coordination.
  • Dates: Period for which Recognition is valid.
  • Standards Year: Date that standards for this recognition evaluation were released.

PCMH - Patient-Centered Medical Home Recognition Program

Patient-Centered Medical Home Recognition Program (PCMH): The Patient-Centered Medical Home is a model of care that puts patients at the forefront of care. PCMHs build better relationships between people and their clinical care teams. NCQA helps primary care practices transform into a PCMH through its Patient-Centered Medical Home Recognition Program. This program evaluates primary care practices that deliver evidence-based, clinically appropriate care while promoting enhanced connections and value-add interactions with other providers and specialists. Research shows that patient-centered medical homes improve quality and reduce costs by preventing expensive and avoidable hospitalizations, emergency room visits and complications. They also improve the patient experience by providing personalized, comprehensive coordinated care that patients want.
  • Anniversary Date: The date which a recognition will lapse if a practice does not take additional action with NCQA.
  • Clinician: The clinicians listed within a practice that has earned PCMH Recognition.
  • Dates: Period for which recognition is valid.
  • Distinctions: Special acknowledgement of achievement in defined categories of providing patient-centered care.
  • Patient Experience: This distinction acknowledges practices that survey patients for satisfaction with the Medical Home version of the CAHPS Clinician and Group Survey. Practices can earn distinction for collecting data through a certified vendor using the standardized survey, following the defined methods and reporting the results to NCQA.
  • Levels: There are three levels of NCQA PCMH Recognition for the 2014 and 2011 standards. NCQA stopped using levels with standards released in 2017 and beyond. Each level reflects the degree to which a practice meets the requirements for the 2014 and 2011 Standards.
    • Level 1: On a scoring scale of 1 –100, the practice has scored 35–59 points and passed all 6 must-pass elements (Patient-Centered Appointment Access, The Practice Team, Use Data for Population Management, Care Planning and Self-Care Support, Referral Tracking and Follow-Up and Implement Continuous Quality Improvement).
    • Level 2: On a scoring scale of 1–100, the practice has scored 60–84 points and passed all 6 must-pass elements (Patient-Centered Appointment Access, The Practice Team, Use Data for Population Management, Care Planning and Self-Care Support, Referral Tracking and Follow-Up and Implement Continuous Quality Improvement).
    • Level 3: On a scoring scale of 1–100, the practice has scored 85–100 points and passed all 6 must-pass elements (Patient-Centered Appointment Access, The Practice Team, Use Data for Population Management, Care Planning and Self-Care Support, Referral Tracking and Follow-Up and Implement Continuous Quality Improvement.)
  • Practice: The practice where recognition was earned.
  • Standards Year: Date that standards for this recognition evaluation were released. This is applicable for standards years prior to 2017 only. As of 2017, standards are updated on an ongoing basis and practices must demonstrate they continue to meet requirements annually.
  • Distinction in Behavioral Health Integration: This distinction acknowledges PCMH practices that have put enhanced structures in place to support the broad needs of patients with behavioral health related conditions within the primary care practice.

PCSP - Patient-Centered Specialty Practice Recognition Program

Patient-Centered Specialty Practice Recognition Program (PCSP): This program evaluates specialty care practices that deliver evidence–based, clinically appropriate care while promoting enhanced connections and value–added interactions with primary care providers and other specialists. Practices must also demonstrate a commitment to supporting the medical home as the hub of patient information, primary care provision and care coordination. PCSP–Recognized practices are also eligible for full automatic credit in the Improvement Activities category of the Merit-Based Incentive Payment System (MIPS) in MACRA, which provides 15% of the total MIPS score.
  • Anniversary Date: The date when a practice's Recognition will lapse if the practice does not fulfill annual reporting requirements.
  • Clinician: The clinicians listed in a practice that has earned PCSP Recognition.
  • Dates: Period for which Recognition is valid.
  • Levels: There are three levels of Recognition for the NCQA 2013 and 2016 standards. (With the 2019 standards and beyond, NCQA stopped using levels.) Each level reflects the degree to which a practice meets the requirements.
    • Level 1: On a scoring scale of 1–100, the practice has scored 25–49 points and passed all 6 must-pass elements (Managing Initial Referrals, Assessing Initial Referral Response, The Practice Team, Medication Management, Test Tracking and Follow-up, Implement and Demonstrate Continuous Quality Improvement).
    • Level 2: On a scoring scale of 1–100, the practice has scored 50–74 points and passed all 6 must-pass elements (Managing Initial Referrals, Assessing Initial Referral Response, The Practice Team, Medication Management, Test Tracking and Follow-up, Implement and Demonstrate Continuous Quality Improvement).
    • Level 3: On a scoring scale of 1–100, the practice has scored 75–100 points and passed all 6 must-pass elements (Managing Initial Referrals, Assessing Initial Referral Response, The Practice Team, Medication Management, Test Tracking and Follow-up, Implement and Demonstrate Continuous Quality Improvement).
  • Practice : The practice that earned Recognition.
  • Standards Year: Date when standards for this Recognition evaluation were released (applicable to standard years prior to 2019). Standards are updated on an ongoing basis and practices must demonstrate they continue to meet requirements annually.

PHP - Population Health Program Accreditation

Population Health Program (PHP) Accreditation: This program evaluates an organization’s application of population health principles to standardize care, become more efficient and manage complex needs better.
  • Date of Next Review: Date of next scheduled evaluation.
  • Data Integration: The ability to use or combine data from multiple sources and databases.
  • Evaluation Product: Accreditation
  • Expiration: Date that accreditation is no longer valid.
  • Intervention: A planned and defined action taken to increase the probability that a desired outcome will occur.
  • Population: All persons in a defined subgroup with specific characteristics, such as a diagnosis, age group or claims history.
  • Population Segmentation: Dividing the population into meaningful subsets using information collected through population assessment and other data sources.
  • Risk Stratification: Uses the potential risk or risk status of individuals to assign them to tiers or subsets.
  • Status: Organization's accreditation standing based upon level of performance.
    • Accredited-3 years: NCQA awards a status of Accredited – 3 years to organizations that demonstrate strong performance of the functions outlined in the standards for CM accreditation.
    • Accredited-2 years: NCQA awards a status of Accredited – 2 years to organizations that demonstrate performance of the functions outlined in the standards for CM accreditation.
    • Denied: NCQA denies Accreditation to organizations that did not meet NCQA requirements during the Accreditation Survey.

PHQ - Physician and Hospital Quality

Physician and Hospital Quality (PHQ): This program evaluates how organizations measure physicians to ensure that measurement methods are fair and rely not only on cost, but also on accepted measures of quality. For hospitals, the standards evaluate if organizations provide members with performance information on hospitals from reliable government and other sources to inform decision-making., which are widely acknowledged to be the most rigorous in the field.
  • Evaluation Product: Certification
    • Hospital Quality: PHQ Hospital Quality Certification is awarded to hospital transparency organizations that meet or exceed NCQA's standards.
    • Physician Quality: PHQ Physician Quality Certification is awarded to physician measurement programs that meet or exceed NCQA's standards.
    • Interim Physician Quality: PHQ Interim Physician Quality Certification is awarded to organizations that have a developed physician measurement program but have not announced planned action or taken that action.
  • Expiration: Date that certification is no longer valid.
  • Status: Organization's certification standing based upon level of performance.
    • Certified: The organization's program meets or exceeds NCQA standards for Physician and Hospital Quality.
    • Denied: The organization's program does not meet NCQA standards for Physician and Hospital Quality.
    • Interim Certification: The organization's program meets NCQA standards for developing a Physician Quality program but has not announced planed action or taken that action.

PN- Provider Network

Provider Network (PN):This program evaluates organizations that provide physician and hospital directories in multiple formats, and determines the availability, accessibility and transparency of an organization′s networks. Organizations with an NCQA Provider Network Accreditation establish appropriate practitioner and provider credentials while ensuring that patients have improved access to care and a better experience.
  • Date of Next Review: The next scheduled survey start date. Accreditation status is determined approximately 90 days after the survey start date.
  • Evaluation Product: Accreditation
  • Expiration: Date that accreditation is no longer valid.
  • Status: Organization's certification standing based upon level of performance.
    • Accredited: The organization's program meets or exceeds NCQA standards for Utilization Management.
    • Denied: The organization's program does not meet NCQA standards for Utilization Management.
    • Under Discretionary Review: NCQA is reviewing an organization to assess the appropriateness of an existing accreditation decision
    • Under Review: The organization's accreditation status is under review at its request.

UM - Utilization Management

Utilization Management (UM):This program assesses organizations that evaluate the appropriateness of requested health care services and make fair and timely determinations about whether to cover requested services.
  • Date of Next Review: The next scheduled survey start date. Accreditation status is determined approximately 90 days after the survey start date.
  • Evaluation Product: Accreditation
  • Expiration: Date that accreditation is no longer valid.
  • Status: Organization's certification standing based upon level of performance.
    • Accredited: The organization's program meets or exceeds NCQA standards for Utilization Management.
    • Denied: The organization's program does not meet NCQA standards for Utilization Management.
    • Under Discretionary Review: NCQA is reviewing an organization to assess the appropriateness of an existing accreditation decision
    • Under Review: The organization's accreditation status is under review at its request.

WHP - Wellness & Health Promotion

Wellness & Health Promotion (WHP): This program evaluates organizations that offer full-service wellness programs. The evaluation uses industry-leading, evidence-based standards to assess key areas of health promotion including how wellness programs are implemented in the workplace, how services such as coaching can empower participants to boost their health and how private health information is protected.
  • Evaluation Product: Accreditation, Certification
    • WHP Accreditation: The organization's programs meet or exceed NCQA standards for Wellness and Health Promotion Accreditation. Accreditation is valid for up to three years from the date of the initial determination.
    • WHP Certification- Health Appraisal: The organization's program meets or exceeds NCQA standards for helping eligible individuals manage their health through Health Appraisals and their results, and by disclosing how it uses the information and how it protects privacy. Standards address the demographic, health and wellness information that must be included in the HA.
    • WHP Certification- Health Coaching: The organization's program meets or exceeds NCQA standards for coaching services that help individuals develop skills to make healthy choices and improve their health. Standards address training and monitoring of coaches and require the organization to refer individuals to other resources, if necessary, such as disease management programs.
    • WHP Certification- Self-Management Tools: The organization's program meets or exceeds NCQA standards for having evidence-based self-management tools to help individuals manage their health. Standards address topics that tools must focus on; call for periodic testing to make sure tools are usable; require review and update of tools to reflect changes in evidence; and require the organization to make tools available in different formats.
  • Expiration: Date that accreditation, certification is no longer valid.
  • Status: Organization's accreditation, certification standing based upon level of performance.
    • Accredited: Meets or exceeds NCQA standards for Wellness and Health Promotion Accreditation.
    • Certified: Meets or exceed NCQA standards for Wellness and Health Promotion Certification.
    • Denied: Did not meet NCQA requirements.

Methodology

Understand how organizations are rated or earn a seal from NCQA.

Learn How

Need More Data?

Get access to valuable insights for your business operations with unparalleled access to health plan performance data and benchmarks.

Get Data

Have Questions?

If you have a specific question, NCQA is ready to help!

Ask a Question

Copyright ©2024 National Committee for Quality Assurance. Review our Terms of Use

rev 3.0.9