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    OpenPayerPolicy UpdatesAdministrative/Operational PolicyPHC California NCQA Policy Update | OpenPayer
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    CurrentPHC CaliforniaPolicy N/A

    PHC-CA National Committee for Quality Assurance Accreditation

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    This policy governs PHC California’s responsibilities for achieving and maintaining NCQA Health Plan Accreditation and Health Equity Accreditation, including readiness monitoring, reporting, document submission, corrective actions, and oversight of delegated entities.

    Policy Summary
    PayerPHC California
    PolicyPHC-CA National Committee for Quality Assurance Accreditation
    Policy CodePolicy N/A
    Change TypeAdministrative reviewno material clinical or coverage change
    Effective DateJanuary 1, 2024
    Last ReviewAug 14, 2026
    Next Review DateN/A
    Key ActionMaintain continuous NCQA readiness through monitoring, evidence validation, deficiency remediation, corrective-action tracking, and quarterly reporting to the QIHEC.
    SourceLink
    POLICY UPDATE CHANGES

    The review history records clerical updates in 2025 and subsequent reviews addressing a DHCS Medical Audit Corrective Action Plan in 2026.

    3 yearsNCQA accreditation results submission interval
    5 working daysInterim approval evidence deadline
    30 daysCompleted report submission deadline
    15 days

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    Site visit notification deadline
    QuarterlyReadiness tracker monitoring

    NCQA Accreditation Readiness and Compliance

    NCQA accreditation readiness and compliance obligations

    The Health Plan must meet all of the following obligations to achieve and maintain NCQA Health Plan Accreditation and NCQA Health Equity Accreditation.

    ALL of the following

    • ALL of the following

      • Achieve and maintain NCQA Health Plan Accreditation and NCQA Health Equity Accreditation.
      • Complete any additional NCQA accreditation programs as directed by DHCS.

    • ALL of the following

      • Monitor applicable NCQA standards and requirements throughout the accreditation cycle.
      • Establish defined performance measures, monitoring activities, and evidence requirements for applicable standards.
      • Periodically validate that policies, procedures, reports, committee documentation, files, and other supporting evidence demonstrate operational compliance.
      • Maintain documentation so it can be retrieved and submitted promptly during NCQA surveys and other accreditation activities.

    • ALL of the following

      • Conduct an NCQA readiness assessment at least annually, including review of applicable standards and updates, responsible business owners, policies and procedures, reports and performance measures, committee and governance documentation, implementation evidence, delegated activities when applicable, operational gaps, and previously identified deficiencies and corrective actions.At least annually
      • Maintain a centralized NCQA readiness tracker or equivalent mechanism and monitor it quarterly.Quarterly

        Track applicable standards or requirements, responsible owners, required evidence, compliance and readiness status, validation dates, gaps or risks, corrective actions, target completion dates, and validation or closure status.

    • ALL of the following

      • Submit NCQA Health Plan Accreditation and Health Equity Accreditation results to DHCS every three years after accreditation is achieved.Every 3 years after accreditation is achieved
      • Provide evidence of interim NCQA Health Plan Accreditation approval to DHCS within five working days of receipt.Within 5 working days of receipt
      • Provide DHCS with accreditation status, survey type, review results, HEDIS and CAHPS summary-level data, recommended actions or improvements, corrective action plans and summaries of findings, and the accreditation expiration date within 30 calendar days after receiving the completed NCQA report.Within 30 calendar days of receipt
      • Notify DHCS of the confirmed NCQA site visit date within 15 calendar days of NCQA confirmation.Within 15 calendar days of NCQA confirmation

    • ALL of the following

      • Make all written materials submitted to NCQA available to DHCS.
      • Allow DHCS representatives to participate in NCQA audit activities, including the NCQA site visit.

    • ALL of the following

      • Identify, document, escalate, and remediate deficiencies in a timely manner.
      • Monitor corrective actions through completion and validate that they are effective and sustainable.
      • Report significant readiness risks and identified deficiencies to the Quality Improvement and Health Equity Committee and the Executive Oversight Committee of the Board of Directors.
      • Comply with corrective actions imposed by NCQA and with corrective actions imposed by DHCS to address a change in accreditation status.

    • ALL of the following

      • Require fully delegated subcontractors and downstream contractors to maintain NCQA accreditation when applicable.
      • Oversee the NCQA accreditation status of fully delegated subcontractors and downstream contractors.

    • ALL of the following

      • Report quarterly monitoring results, including identified risks, deficiencies, and corrective action status, to the Quality Improvement and Health Equity Committee to support ongoing oversight and sustained accreditation readiness.Quarterly

    Accreditation Reporting and Readiness Frequencies

    NCQA Accreditation Result Submission
    Submission intervalEvery 3 years after NCQA accreditation is achieved
    Accreditation results coveredNCQA Health Plan Accreditation and Health Equity Accreditation results
    RecipientCalifornia Department of Health Care Services (DHCS)
    Interim Approval Evidence
    Submission deadlineWithin 5 working days of receipt
    Required evidenceEvidence of interim NCQA Health Plan Accreditation approval
    Recipient

    Health Plan Responsibilities

    Documentation Required

    Submit NCQA accreditation information to DHCS

    Submit NCQA Health Plan Accreditation and Health Equity Accreditation results to DHCS every three years once accreditation is achieved. Provide interim NCQA HPA approval evidence within five working days of receipt and submit required status and review components within 30 calendar days of receiving the completed NCQA report.

    • Include accreditation status, survey type, results of the review, HEDIS® and CAHPS® summary-level data, recommended actions or improvements, corrective action plans and summaries of findings, and the accreditation expiration date.
    • Notify DHCS of the NCQA site visit date within 15 calendar days of NCQA confirmation.
    Documentation Required

    Support DHCS participation in NCQA audits

    Make all written materials submitted to NCQA available to DHCS and allow DHCS representatives to participate in NCQA audit activities, including the NCQA site visit.

    Health Equity Accreditation

    Health Equity Accreditation
    PurposeBuild an internal culture that supports health equity
    Language and network focusCreate and offer language services and provider networks mindful of individuals’ cultural and linguistic needs
    Care objectiveReduce health inequities and improve care
    Policy Summary
    PayerPHC California
    PolicyPHC-CA National Committee for Quality Assurance Accreditation
    Policy CodePolicy N/A
    Change TypeAdministrative reviewno material clinical or coverage change
    Effective DateJanuary 1, 2024
    Last ReviewAug 14, 2026
    Next Review DateN/A
    Key ActionMaintain continuous NCQA readiness through monitoring, evidence validation, deficiency remediation, corrective-action tracking, and quarterly reporting to the QIHEC.
    SourceLink
    On This Page
    NCQA Accreditation Readiness and ComplianceAccreditation Reporting and Readiness FrequenciesHealth Plan ResponsibilitiesHealth Equity Accreditation
  1. Notify DHCS of any change in NCQA Health Plan Accreditation or Health Equity Accreditation status within 30 calendar days after receiving the final NCQA report.Within 30 calendar days of receipt of the final NCQA report
    2. California Department of Health Care Services (DHCS)
    Completed NCQA Report
    Submission deadlineWithin 30 calendar days of receipt of the completed report from NCQA
    Required submissionNCQA Health Plan Accreditation and Health Equity Accreditation status and review components
    Examples of required componentsAccreditation status, survey type, review results, performance summaries, recommended actions, corrective action information, and accreditation expiration date
    NCQA Site Visit Notification
    Notification deadlineWithin 15 calendar days of confirmation of the site visit by NCQA
    Information to reportThe date of the NCQA site visit
    RecipientCalifornia Department of Health Care Services (DHCS)
    Accreditation Status Changes
    Notification deadlineWithin 30 calendar days of receipt of the final NCQA report
    Change to reportAny change in NCQA Health Plan Accreditation or Health Equity Accreditation status
    Follow-up obligationComply with corrective actions imposed by NCQA or DHCS
    NCQA Readiness Assessment
    Assessment frequencyAt least annually
    Standards reviewAssess readiness against applicable NCQA standards and updates
    Assessment scopeReview responsible business owners, policies and procedures, reports and performance measures, governance records, implementation evidence, delegated activities, gaps, deficiencies, and corrective actions
    NCQA Readiness Tracker
    Monitoring frequencyQuarterly
    Monitoring mechanismA centralized NCQA readiness tracker or equivalent mechanism
    Oversight reportingQuarterly results, including risks, deficiencies, and corrective action status, are reported to the QIHEC
    Documentation Required

    Report accreditation status changes and corrective actions

    Notify DHCS of any change in NCQA Health Plan Accreditation or Health Equity Accreditation status within 30 calendar days of receiving the final NCQA report. Comply with corrective actions imposed by both NCQA and DHCS to address changes in accreditation status.

    Documentation Required

    Oversee delegated entity accreditation

    If fully delegated subcontractors or downstream contractors are engaged, require those entities to also have NCQA accreditation and oversee their accreditation status.

    Documentation Required

    Maintain continuous NCQA readiness

    Maintain continuous NCQA readiness through ongoing monitoring, evidence validation, timely deficiency remediation, and corrective-action oversight. Maintain a centralized NCQA readiness tracker or equivalent mechanism, monitor it quarterly, and report identified risks, deficiencies, and corrective-action status to the QIHEC.

    • Conduct ongoing monitoring of applicable NCQA requirements and periodically validate policies, procedures, reports, committee documentation, files, and other supporting evidence.
    • Identify, document, escalate, and remediate deficiencies in a timely manner; monitor corrective actions through completion and validate that they are effective and sustainable.
    • Track applicable standards or requirements, responsible owners, required evidence, compliance and readiness status, validation dates, gaps or risks, corrective actions, target completion dates, and validation or closure status.
    • Report significant readiness risks and identified deficiencies to the QIHEC and the Executive Oversight Committee of the Board of Directors.