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Provider Manual

National Committee for Quality Assurance

Last Updated on August 23, 2018

An overview

The National Committee for Quality Assurance (NCQA) is a private, not-for-profit organization dedicated to improving the quality of health care. The organization’s primary activities are assessing and reporting on the quality of the nation’s managed care plans. NCQA is governed by a Board of Directors that includes employers, consumer and labor representatives, health plans, quality experts, policy makers, and representatives from organized medicine. Security Health Plan is NCQA accredited and has maintained accreditation since 2002.

NCQA began accrediting managed care organizations in 1991 in response to the need for standardized, objective information about the quality of these organizations. During an accreditation survey, plans are reviewed against more than 70 standards, each of which focuses on an important aspect of the health plan. These standards fall into five broad categories:

  • Access and service – Do health plan members have access to the care and services they need? For example: are doctors in the health plan free to discuss all treatment options available? Do patients report problems getting needed care? How well does the health plan follow up on grievances?
  • Qualified providers – Does the health plan assess each doctor’s qualifications and what health plan members say about their providers? For example: Does the health plan regularly check the licenses and training of physicians? How do health plan members rate their personal doctor or nurse?
  • Staying healthy – Does the health plan help people maintain good health and avoid illness? Does it give its doctors guidelines about how to provide appropriate preventive health services? Are members receiving tests and screenings as appropriate?
  • Getting better – How well does the health plan care for people when they become sick? How does the health plan evaluate new medical procedures, drugs and devices to ensure that patients have access to safe and effective care?
  • Living with illness – How well does the health plan care for people with chronic conditions? Does the plan have programs in place to assist patients in managing chronic conditions such as asthma? Do diabetics, who are at risk for blindness, receive eye exams as needed?

NCQA accreditation surveys, which consist of on-site and off-site components, are conducted by teams of physicians and managed-care experts. A national oversight committee of physicians analyzes the team’s findings and assigns one of five possible accreditation levels (excellent, commendable, accredited, provisional or denied) based on the plan’s level of compliance with NCQA standards, HEDIS® and CAHPS® results.