National Committee for Quality Assurance Standards

The National Committee for Quality Assurance (NCQA) regularly updates and maintains quality standards utilized by the health insurance industry to gauge levels of ongoing quality and improvement. Overall, the standards include more than 1,500 requirements that involve Blue Cross NC business areas across the enterprise. Plans are audited by NCQA on a three-year cycle which includes a rigorous on- and off-site survey process. Below is a summary of the five quality standard categories Blue Cross NC uses and is audited against. These categories are central to our 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.

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

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