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Quality standards

We adhere to the quality standards set by the National Committee for Quality Assurance (NCQA), a nonprofit dedicated to improving health care quality.

National Committee for Quality Assurance Standards

The National Committee for Quality Assurance (NCQA), is a private, nonprofit organization dedicated to improving health care quality.  NCQA accredits and certifies a wide range of health care organizations. NCQA's Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used performance measurement tool in health care.12 NCQA maintains and regularly updates quality standards utilized by the health insurance industry to gauge levels of ongoing quality and improvement. These requirements are central to our Quality Improvement Program that is designed to focus on the physical, mental, and social well-being of its members. Blue Cross NC chooses NCQA's Health Plan (HP) Accreditation process because the guidelines and standards provide a quality framework that contain key improvement activities that are most important for member safety and consumer protection.

NCQA HP Accreditation surveys include rigorous on-site and off-site evaluations of over 60 standards and selected HEDIS® measures.12 Year-round, Blue Cross NC works to maintain its Accreditation by adherence to NCQA's Standard and Guidelines for the Accreditation of Health Plans and most recently completed the reaccreditation process in March 2023. NCQA has awarded Blue Cross NC an accreditation status of 'Accredited' for service and clinical quality that meet the requirements of NCQA's rigorous standards for consumer protection and quality improvement. NCQA performs quality review on the following Blue Cross NC product lines: Commercial PPO, Commercial POS, Commercial EPO, and On-exchange PPO, On-exchange POS and On-exchange EPO.

NCQA regularly updates and maintains quality standards utilized by the health insurance industry to gauge levels of ongoing quality and improvement. Health Plans are surveyed on a three-year cycle that includes an audit of on-going NCQA activities conducted throughout each year. NCQA Health Plan Accreditation survey include rigorous on-site and off-site evaluations. Below is a summary of the six quality standard categories Blue Cross NC follows per NCQA's Guidelines and Standards for the Accreditation of Health Plans.1 These categories are central to Blue Cross NC's Quality Improvement Program designed to improve quality, safety, and member experience.

Quality Management and Improvement (QI)

Implementing corrective actions based on assessment results, aimed at addressing identified deficiencies and improving outcome.1

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.1

Credentialing and Recredentialing (CR)

A process by which an organization reviews and evaluates qualifications of licensed independent practitioners to provide services to its members.1

Members Experience (ME)

A process by which the organization provides members with access to health care information and tools to better manage their health. 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.1

Population Health Management (PHM)

Addressing the care needs of the organization's membership population across the continuum of care.3

Network Management (NET)

The process by which an organization works to maintain an adequate network of health care practitioners and providers to meet the needs and preferences of its membership.2

Consumers can easily access organizations' NCQA statuses and other information on health care quality on NCQA's website, or by calling NCQA Customer Support at 888-275-7585.2 If you have any questions related to Blue Cross NC's NCQA Quality Improvement Program, please contact your regional Strategic Provider Relations Consultant.