To evaluate members' access to the health plan, NCQA reviews health plan records, interviews health plan staff and grades results from consumer surveys conducted by independent survey organizations. NCQA looks for:

• a well-defined process that the health plan uses to make decisions about covering medical treatments and services for plan members.
• fair and consistent health plan decisions about medical treatments and services provided to plan members.
• evidence that qualified health plan professionals make decisions about medical treatments and services provided to plan members.
• a process for evaluating new medical procedures, drugs and devices.
• evidence that plan members get needed emergency services.
• procedures that ensure health plan members get the level of care they need.
• evidence of improving the availability of doctors and other practitioners.
• evidence of improving access to primary care and behavioral health care and to customer support.
• policies that define the rights and responsibilities of plan members.
• effective communications that make plan members aware of their rights and responsibilities.
• information that clearly informs plan members about services, benefits and how the plan works.
• processes that protect the confidentiality of information and medical records of plan members.
• accurate and thorough information about the health plan to prospective members.

To evaluate the service the health plan provides to plan members, NCQA reviews health plan records, interviews health plan staff and grades the results from consumer surveys conducted by independent survey organizations. NCQA looks for:

• prompt decisions about coverage of medical treatments and services for plan members.
• evidence that health plans’ decisions about medical treatment and service are based on acceptable standards for medical practice.
• clear communications from the health plan to members and doctors about reasons for denying medical treatments or services and about the process for appealing plan decisions to deny treatment or services.
• processes to resolve member complaints and appeals of health plan decisions.
• evidence of fair and prompt handling of complaints and appeals from plan members.
• members’ and doctors’ satisfaction with how the health plan makes decisions about coverage of medical treatments and services for plan members.
• policies that ensure that the drugs the health plan covers are safe and effective and that plans give members the right to appeal for coverage of drugs not normally covered.
• evidence of improving members’ satisfaction with the health plan.
• processes for the coordination of care so that plan members receive the right care at the right time
• health plan members’ reports about how difficult it is for them to get needed care; specifically, how much of a problem did members have getting a personal doctor they are happy with, a referral to a specialist, care they thought was necessary and approvals for care.
• health plan members’ reports about how often they received care quickly; specifically, how often did members get advice as needed, timely appointments for routine care, prompt care for illness or injury and short waits at the doctor’s office.
• health plan members’ reports about how often they experienced courteous, respectful and helpful staff at the doctor’s office.
• health plan members’ opinions about how difficult it was for them to good customer service; specifically, how much of a problem did members have finding or understanding written information, getting help from customer service or completing paperwork from the health plan.
• health plan members’ reports about how often their health plan paid claims in a reasonable time and correctly.
• health plan members’ ratings of all their experiences with their health plan.
• a well-defined program for continuously improving the quality of clinical care and service provided to plan members.
• individuals in the health plan responsible for overseeing quality improvement programs.
• actual improvements that the plan has made in care and service.

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