National Committee for Quality Assurance Standards

The National Committee for Quality Assurance (NCQA) maintains and regularly updates quality standards utilized by the health insurance industry to gauge levels of ongoing quality and improvement. Overall, the standards include over 750 factors and 1,200 requirements that involve business areas across the organization.

Quality Management and Improvement (QI)

Implementing corrective actions based on assessment results, aimed at addressing identified deficiencies and improving outcome. See the annual Quality Improvement Program Evaluation Summary.

Utilization Management (UM)

Evaluating and determining coverage for and appropriateness of medical care services, as well as providing needed assistance to clinician or patient, in cooperation with other parties, to ensure appropriate use of resources.

Credentialing and Recredentialing (CR)

A process by which an organization reviews and evaluates qualifications of licensed independent practitioners to provide services to its members.

Members' Rights and Responsibilities (RR)

Communicating information to member's that specifies their rights and responsibilities related to a mutually respectful relationship with the organization, addressing complaints and appeals, benefits and access to medical services, choosing physicians and hospitals, their privacy and confidentiality, and accurate coverage materials.

Member Connections (MEM)

A process by which the organization provides members with access to health care information and tools to better manage their health.

More information about NCQA is available at www.NCQA.org.

If you have any questions related to BCBSNC's NCQA standards, please contact your regional Strategic Provider Relations Consultant.