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Accreditation Standards for the NCQA

The National Committee for Quality Assurance (NCQA), founded in 1990, is a non-profit whose mission is to improve health care quality and increase awareness on the subject at the national level. Over 70 percent of Americans participate in NCQA accredited programs, which can be found in every state. NCQA has an in-depth accreditation process for organizations providing healthcare, involving more than 60 standards that are reviewed annually.

  1. Consolidated Guidelines

    • In the past, NCQA had separate accreditation processes for MCO and PPO programs, but has since developed shared guidelines and standards known as the Health Plan Accreditation Program. This set of guidelines applies to HMOs, MCOs, PPOs and POSs, with the purpose being to aid both employers and the public in choosing between plans.

    Evaluation Process and Criteria

    • NCQA's initial evaluation, which may or may not lead to accreditation, examines over 40 key areas of an organization's healthcare plan. These areas include program structure, practitioner availability, case management, clinic guidelines and member satisfaction, among others. Additionally, NCQA looks at the results achieved so far in care, efficiency and service. To carry out the evaluation, a team of experts visits the facilities, interviewing staff, examining plan documents and administering detailed surveys.

    Onsite and Offsite Surveys

    • NCQA conducts both onsite and offsite surveys of organizations to get a thorough and well-rounded idea of what the programs look like. The offsite survey is conducted online through Interactive Survey Systems (ISS), and information provided is checked against NCQA accreditation standards to judge an organization's readiness and indicators of future success. The onsite survey involves a special team of physicians and care experts who visit for two days, talking with staff and probing guidelines and policy documents.

    Analysis and Judgement

    • Once the surveys have been completed, the Review Oversight Committee (ROC), a panel consisting of doctors from around the US, evaluates the results and gives the organization one of four levels of accreditation. The ROC may also choose to deny the organization accreditation. After an accreditation status has been assigned, there are ongoing reviews to ensure the organization is still a quality healthcare provider.

    Levels of Accreditation

    • There are four NCQA accreditation levels. The highest is excellent, which is awarded to those organizations whose programs meet or surpass required standards for the protection of consumers and quality in practice. Commendable accreditation is given to those who have longstanding programs that meet required standards. Accredited status goes to organizations that meet the basic required standards. If an organization needs to further improve its programs to achieve the basic accredited level, NCQA will assign provisional status. Organizations that do not at least meet provisional standards are denied.

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