For organizations that have successfully achieved URAC accreditation, pursuing NCQA Health Plan Accreditation often seems like the logical next step. After all, both programs emphasize quality, accountability, member protection, and continuous improvement.

Many organizations begin the process assuming that because they already meet one nationally recognized accreditation program, earning the other will simply require mapping existing policies and making a few adjustments.

Unfortunately, that assumption can lead to frustration, unexpected work, and missed scoring opportunities.

The good news? Organizations with URAC accreditation already have many of the foundational processes needed for NCQA success. The challenge is understanding where the expectations—and the evidence required—differ.

Here are twelve of the biggest surprises organizations encounter when preparing for NCQA Health Plan Accreditation.

1. Policies Alone Don’t Earn Points

URAC-accredited organizations often have exceptionally well-developed policies and procedures. Those documents provide a strong starting point.

NCQA, however, typically expects organizations to demonstrate that policies are consistently implemented throughout the organization. Surveyors evaluate not only what is written but also whether operational evidence supports that the process is functioning as intended.

The question shifts from:

“Do you have a policy?”

to

“Can you demonstrate that staff consistently follow it?”

2. Data Becomes Central to Nearly Every Standard

One of the first surprises is the amount of quantitative analysis required.

Organizations frequently need to demonstrate:

• Performance monitoring
• Trend analysis
• Goal achievement
• Root cause analysis
• Improvement activities
• Reassessment after interventions

Collecting data is only the beginning. NCQA expects organizations to explain what the data means and what actions were taken because of it.

3. Continuous Improvement Is More Than Annual Reporting

Many organizations already maintain quality committees and produce performance reports.

NCQA expects something more dynamic.

Successful organizations routinely ask:

• What problem did we identify?
• What intervention did we implement?
• Did it improve performance?
• If not, what are we changing next?

That closed-loop improvement process appears throughout the accreditation standards.

4. File Reviews Carry Significant Weight

One of the greatest sources of anxiety is the survey file review, and for good reason! All but complex case management are must-pass requirements. Scoring below 90% will cause Provisional Accreditation and a Corrective Action Plan.

During accreditation, surveyors evaluate actual case documentation—not just written procedures. Staff turnover that affects compliance? It’s sad and problematic, but not an excuse.

Even organizations with outstanding clinical operations sometimes discover documentation inconsistencies that affect scoring.

Preparation should include multiple mock file reviews well before survey submission.

5. Committee Minutes Become Evidence

Committee minutes often evolve from simple meeting summaries into accreditation documents.

NCQA expects minutes that demonstrate:

• Analysis
• Discussion
• Decisions
• Assigned actions
• Follow-up
• Leadership oversight

Strong minutes tell the story of how quality is managed throughout the organization. Remember the adage, “If you didn’t document it, you didn’t do it”? You cannot talk your way out of no documentation. It’s there or it’s not.

6. Delegation Oversight Is More Comprehensive Than Expected

Organizations relying on delegated vendors frequently underestimate the documentation required.

Surveyors look for evidence of:

• Pre-delegation evaluation
• Ongoing monitoring
• Annual evaluation
• Corrective action when needed
• Performance reporting
• Executive oversight

Vendor management becomes an ongoing governance function rather than a contractual activity. Episodic check points with those who are performing the standards on your behalf do not make the grade. Timelines are strict for a reason – they are your members and you are ultimately responsible for their care that you have delegated to other entities.

7. Executive Leadership Plays a Visible Role

Accreditation cannot remain solely within the Quality or Compliance department.

Successful NCQA organizations demonstrate active participation from executive leadership through:

• Resource allocation
• Committee participation
• Strategic oversight
• Accountability for performance
• Organizational priorities

Leadership engagement is evident throughout the accreditation process. They are critical to support the accreditation team for removing barriers when excitement or progress lags and everyone is “doing” NCQA off the side of their desks.

8. Cross-Department Collaboration Is Essential

NCQA accreditation touches nearly every operational area.

Among the departments commonly involved are:

• Utilization Management
• Care Management
• Quality Improvement
• Credentialing
• Provider Network Management
• Appeals
• Member Services
• Pharmacy
• Behavioral Health
• Population Health
• Compliance
• Information Technology

Organizations that distribute ownership across departments generally experience smoother accreditation journeys. It truly does take a village to make sure that all T's are crossed and I's are dotted in the allotted timeframe.

9. Documentation Must Tell the Story

Many organizations are already performing excellent work.

The challenge is demonstrating it.

Successful documentation explains:

• What happened
• Why it happened
• What decision was made
• Who approved it
• What action followed
• Whether the intervention improved results

Surveyors should be able to understand the organization’s decision-making process and follow the story line simply by reviewing the evidence. Surveyors do not have time to identify all the dot points and then connect them. That’s your job in presenting your organization.

10. Reporting Capabilities Matter More Than Expected

Organizations occasionally discover that existing systems cannot easily generate reports required for accreditation.

Examples include:

• Turnaround times
• Appeal outcomes
• Denial statistics
• Practitioner access and availability
• Delegation monitoring
• Quality measure trends
• Intervention effectiveness

Developing these reporting capabilities always takes longer than anticipated.

11. Accreditation Becomes an Organizational Management System

Perhaps the biggest surprise is that NCQA accreditation is not simply a compliance exercise.

High-performing organizations use accreditation to strengthen:

• Governance
• Operational accountability
• Performance management
• Quality improvement
• Executive decision-making

Rather than preparing for survey every three years, they build accreditation into everyday operations.

12. Success Depends on Correct Interpretation—Not Just Documentation

Organizations often arrive with excellent documentation but struggle because they interpret standards differently than surveyors.

Understanding the intent behind each standard is just as important as producing evidence.

Experienced guidance can help organizations avoid spending valuable time documenting activities that do not fully meet scoring expectations while identifying opportunities to leverage work they are already doing.

The Bottom Line

Organizations with URAC accreditation begin the NCQA journey from a position of strength. They typically have mature operational processes, committed leadership, and a culture focused on quality.

The transition is rarely about starting over.

Instead, it involves enhancing governance, strengthening documentation, expanding performance measurement, preparing for rigorous file reviews, and demonstrating continuous improvement in the ways NCQA expects.

With thoughtful planning, organizations often discover they are much closer to NCQA readiness than they initially believed—they simply need to present their work through a different accreditation lens.

At Managed Healthcare Resources (MHR), we’ve helped health plans navigate both accreditation frameworks. We understand where the standards align, where they differ, and how organizations can leverage existing strengths to build a successful NCQA accreditation strategy without reinventing their operations.

Wondering how your current URAC processes align with NCQA requirements?

Talk with an MHR accreditation specialist to learn where the standards overlap, where they differ, and what steps can accelerate your accreditation journey.

Start the conversation with MHR. 

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