Requirements for NCQA-Certified

The Healthcare industry requires constant monitoring and evaluation to ensure the best service delivery, availability of protocols, and elimination of discriminatory acts which can affect healthcare delivery. NCQA accreditation services certify that the credentialing service or agency has met various standards and credentialing accreditation requirements. The bigger picture is to ensure the organization implements the best standard practices and has the proper infrastructure and resources to boost service quality.  

NCQA is one of the agencies responsible for monitoring the healthcare industry to ensure the right documentation and protocols for service delivery. Any organization seeking certification must meet specific data requirements. Here are the data requirements needed for accreditation.

The credentialing services and activities

Verification of the credentials is for the individuals, employees, and agencies intending to offer the services. They must provide all the needed credentials and certifications to be verified by a team of the credentialing committee. This is the first stage of getting the NCQA certification and accreditation. 

The second process involves monitoring the agency or the individuals for any sanctions, complaints, and quality issues that may affect the entire process. The sanction, complaints, and quality monitoring issues must be done in every re-credentialing cycle. The agency must apply for the credentialing before accreditation ends, allowing a sufficient period for investigation before NCQA offers the new certification. 

There are other factors to consider during credentialing. For instance, the credentialing organization must be licensed by the following: 

  • health maintenance organization (HMO)
  • point of service (PoS)
  • preferred provider organization (PPO)
  • exclusive provider organization (EPO). 

Any organization seeking NCQA accreditation as a health plan or managed behavioral health organization (MBHO) will not be eligible for the credentialing process. The credentialing organization must apply to perform functions directly or through a contractual agreement with NCQA. They must also offer the services to at least 50% of the practitioner clients and organization. 

NCQA will always review the credentialing organization’s policies and procedures to ensure they abide by the NCQA quality standards. Therefore, before the NCQA licenses them to credentialing services, they must provide their policies and organizational guidelines to the NCQA for review. Besides, you can partner with various organizations to conduct the review process; however, you should consider the NCQA-Certified CVO credentialing team at Andros due to their experience in offering such services.

NCQA credentialing accreditation requirements

When applying for credentialing accreditation, NCQA will focus on the following factors.

  1. Organization data requirements
  • The type of practitioners to be accredited

The first focus is on the organization’s policies and standard of practice, including a review of the medical and behavioral healthcare teams. This team includes medical doctors, nurses, specialists, especially action medicine specialists, clinical social workers, psychologists, and oral surgeons.

  • Decision-making data requirements

NCQA also focuses on decision-making structures and processes. All the practices must have the necessary credentials before offering any medical services. The organization must also have a structured process for credentialing decisions and determine the practitioners allowed to participate in the network. All the decision-making files must be provided to the NCQA for review and approval before they are used for decision-making. The organization must also offer Medicare and Medicaid sanctions and accreditation.

  • Quality issues and concerns

The organization must include information about previous complaints and adverse events, including additional details about previous lawsuits, consumer complaints, and loss of license due to other details. Organizations must have a good standing with regulatory bodies and be approved by all the relevant accrediting entities. Therefore, they must attach all the certifications, licenses, regulatory violations, and ongoing investigations.

  • Data confidentiality and security protocols

An organization must also ensure data confidentiality and security protocols for accreditation. For instance, the organization must provide all the data confidentiality, security, and privacy protocols implemented. This will also include a review of data security structures, systems used, and the individuals in charge of the process. Part of the security protocols will also involve the organization stating how to limit access to practitioner data related to accreditation and credentials.

  1. Practitioner data requirements

The practitioners must provide the following data requirements for the review process.

  • Personal identity data

This includes a driver’s license, social security number, and a valid address. They must also have an accurate and current drug enforcement administration (DEA) or controlled and dangerous substance (CDS) certification, whichever is available. This means they must undergo a drug test before they apply for accreditation.

  • Practice data requirements

Practitioners must provide a copy of their valid medical license and certification. Within the documents, they must attach education certifications up to the latest and the highest certification. They must also attach the certificate and licenses related to board and professional qualification and accreditation statuses.

  • Historical data requirements

This includes the history of loss of license due to disciplinary and investigative actions and protocols. This will also contain the duration of the license issue. Practitioners must also provide felony convictions, disciplinary actions, and other legal-related investigations ordered by law enforcement agencies at the state or federal levels.

  • The current malpractice insurance

This must state the duration of coverage, premiums, and any settlement history within a given period. Other documents include a work history and professional liability claims that led to settlements within the stipulated duration.

  1. Nondiscriminatory credentialing policies and requirements

Based on the provided policies and structures, NCQA grades the organizations based on the efficiency of their decision-making structures and monitoring measures to prevent discrimination. The nondiscriminatory credentials and documentation must also spell out how to stop discrimination and list the available measures, policies, and systems in place to eliminate discrimination. They must also include monitoring tools such as audit files and systems to prevent potential biases and practitioner complaints related to preferences. 

Once the practitioner and the organization provide the needed data and information, the NCQA committee sets up a real or virtual meeting to discuss the details and then communicate the findings through emails or letters to the organization.

NCQA analysis protocols

NCQA relies on the provided information and finals plus additional external sources to evaluate the practitioner and accomplish the NCQA analysis process. In case of discrepancies, it will contact the practitioner to notify them about the differences and seek clarification; this process will determine whether the practitioner gets the accreditation. 

Based on the available reports, the organization can advise its practitioner to correct the information provided to prevent further mistakes upon the next renewal cycle. The organization must also allow the practitioners sufficient time to review their documentation and information before accreditation requests. 

Benefits of NCQA accreditation

Accreditation and services are critical for boosting the industry’s best practices when delivering healthcare and other medical services. The certification also demonstrates your organization’s qualification to offer the best services. This will boost the organization’s reputation with regulatory bodies, clients, the government, and other partners such as insurance services providers. 

Adhering to the NCQA requirements enables the organization to comply with state and federal laws. Besides, the compliance, qualifications, and standard practices help the organization to increase its revenue stream from various healthcare service providers.


Any organization applying for NCQA accreditation must have all the appropriate insurance coverage and licenses by various regulatory bodies and provide different data security and discrimination prevention files. The organization must also provide a copy of multiple policies and guidelines to ensure compliance with the NCQA standards. Additional documentation about the practitioners must also be included in the application documents. The practitioner details include personal details, insurance coverage and claims, licenses, education certifications, and drug test certifications. The NCQA committee will review these documents to determine whether the practitioner or the organization qualifies for accreditation.