NCQA Accreditation

The National Committee for Quality Assurance (NCQA) is an independent, non-profit organization that assesses managed care organizations´ quality of care and services through complementary activities—accreditation reviews, and developing, auditing and reporting performance measures.

NCQA began conducting accreditation reviews in 1991. The NCQA accreditation process is a thorough and rigorous assessment of the quality assurance systems of managed care organizations (MCO). The review evaluates how well a health plan manages its entire delivery system—physicians, hospitals, providers and administrative services—in order to continuously improve health care for its members. Teams of highly qualified health care professionals, predominantly physicians, conduct these detailed on-site and off-site reviews. The teams´ findings are analyzed, based on NCQA’s published standards, by a national oversight committee comprised of physicians convened by NCQA. NCQA’s 50 Accreditation Standards are applied to the following categories: Quality Improvement, Physician Credentials, Members´ Rights and Responsibilities, Preventive Health Services, Utilization Management and Medical Records.

In 2000, NCQA began providing additional details about health plan performance in various areas of care and service that are important to consumers. To make this information easier to interpret, performance on NCQA standards and results of HEDIS measures are reported across a set of performance categories:

Access and Service
Qualified Staying Healthy
Getting Better
Living with Illness

NCQA has several levels of accreditation, which are described briefly below:

Excellent: NCQA’s highest accreditation status is granted only to those plans that demonstrate levels of service and clinical quality that meet or exceed NCQA’s rigorous requirements for consumer protection and quality improvement. Plans earning this accreditation level must also achieve HEDIS results that are in the highest range of national or regional performance.

Commendable: This accreditation level is awarded to plans that demonstrate levels of service and clinical quality that meet or exceed NCQA’s rigorous requirements for consumer protection and quality improvement.

Accredited: Health plans that earn the ´Accredited´ designation must meet most of NCQA’s requirements for consumer protection and quality improvement.

Provisional: This level of accreditation is granted for one year to plans that have adequate quality improvement programs and meet many of NCQA standards. These plans need to demonstrate progress before they can qualify for higher levels of accreditation.

How Should Consumers and Purchasers Use the List?

Accreditation status is not a guarantee of the quality of care that any individual patient will receive or that any individual physician or other provider delivers. However, plans that are accredited have demonstrated that they provide the consumer protections required by NCQA standards and that they closely monitor, and are continuously improving, the quality of care they deliver.

Health Plan Reviews