Decoding the Direct Link Between Efficient Appeals & Grievances and Strong NCQA Scores

When it comes to National Committee for Quality Assurance (NCQA) accreditation, health plans know that it’s more than just a stamp of approval. It’s a powerful marker of quality, operational integrity, and member-first care. In fact, in many states, Medicaid agencies make NCQA accreditation a requirement for health plans to even bid for new business.

While the NCQA’s standards set the bar for quality, meeting them day after day can feel like a grueling climb, with your team carrying a heavy load

Deconstructing the NCQA Compliance Challenge

On paper, NCQA standards are straightforward, i.e., demonstrate that you can capture, classify, resolve, and learn from every appeal and grievance (A&G) with consistency, timeliness, and transparency.

However, in practice? Securing and sustaining NCQA accreditation demands precise orchestration of data, documentation, and process excellence across multiple domains, such as Utilization Management (UM), Medicare Advantage, Medicaid, and Member Experience.

It’s one of the trickiest pieces to get right. Why? Often because A&G processes are rooted in manual, fragmented, and heavily dependent on legacy tools like spreadsheets, disconnected databases, and paper trails.

When member grievances slip through the cracks, it’s more than just an internal problem, it creates a ripple effect of risk. Here’s what’s really at stake:

• Audits become a nightmare: Missed deadlines (SLAs) are red flags for NCQA auditors, and gaps in your paperwork turn the process into a stressful scramble
• Costs creep up, and morale dips: Your team burns out trying to manage the chaos manually, leading to rising overhead and frustrating inefficiencies
• You inadvertently make the problem worse: Ineffective handling doesn’t resolve issues; it amplifies them, leading to even more complaints and frustrated members

Your reputation takes a hit. Ultimately, this all leads to lower CAHPS® and HEDIS® scores, the very metrics that measure trust and quality in the eyes of your members and the market.

Simplifying Accreditation through the Lens of Intelligent Automation

So how do health plans move beyond spreadsheets and silos to something more sustainable?

The answer lies in intelligent automation. Health plans can embed artificial intelligence (AI) and process intelligence directly into day-to-day operations, and can take compliance from being an afterthought to a continuous state of readiness.

Think of it this way: instead of teams spending hours categorizing cases, chasing deadlines, or preparing an audit, automation does that groundwork in real time. Cases are classified when they arrive, routed to the right team without delay, and tracked against service levels automatically. Every action is logged, so audit documentation isn’t a separate project.

That’s precisely the approach behind Newgen’s AI-first Complaints, Appeals & Grievances (CAG) Suite. Designed with NCQA’s standards in mind and complying with CMS protocols, the suite helps payers turn accreditation into a predictable, repeatable, and intelligence-driven process.

Every complaint, appeal, grievance, and external review is tracked from intake to resolution. The outcome is a significant reduction in manual rework, better compliance & readiness, and a measurable uplift in member experience. Key capabilities under the hood:

• AI-driven case classification to cut manual rework
• Audit-ready documentation baked into every workflow
• Real-time SLA tracking to stay ahead of compliance deadlines
• Intelligent routing to get the right case to the right team, faster

With AI and automation, compliance shifts from a box-checking list to a built-in capability i.e. always on, always ready, and stress-free.

Impact Beyond Just Accreditation

For health plans, NCQA accreditation is only one part of the bigger picture. The real opportunity lies in using compliance as a springboard to transform operations, strengthen member trust, and reduce administrative slop. With Newgen’s CAG Suite, payers are empowered to replace fractured legacy operations with a unified, low-code, cloud-native platform. The payoff is strategic:

• Transparency with centralized dashboards for end-to-end visibility
• Adaptability to quickly respond to evolving NCQA or CMS standards
• Automation-first compliance to ensure NCQA elements are met proactively
• Member-first trust through timely, contextual, and automated member communications
• Predictive intelligence to identify risks, care gaps, and SLA breach trends before they occur

Ready to Optimize NCQA?

Validate your members, regulators, and partners that help deliver consistent, equitable, and high-quality care. With Newgen’s CAG Suite, health plans can ensure:

• Continuous compliance built into daily operations
• Reduced cost by cutting manual work and duplication
• Improved rating through better CAHPS® and HEDIS® performance
• Stronger competitiveness in securing Medicaid and other lines of business

It’s time to stop viewing accreditation as an obligation and leverage it as an advantage.

The Newgen Health Team is here to walk you through the complete process.

Talk to our experts today and learn how Newgen’s CAG Suite can help you accelerate your NCQA alignment strategy.