URAC Transitions of Care Designation
URAC TOC Designation vs. Other Transitions of Care Frameworks
How URAC's Transitions of Care Designation compares to NCQA, Joint Commission, and CMS transitions of care requirements — and why the right framework depends on your organization type, base accreditation, and contractual environment.
Schedule a Free Discovery SessionWhy Framework Selection Matters
Multiple accreditation bodies and regulatory frameworks address transitions of care. The frameworks are not interchangeable — they differ in scope, eligible organization types, the specificity of their standards, how compliance is evaluated, and what credential or recognition results from the process.
For organizations already holding — or pursuing — a URAC base accreditation, the URAC TOC Designation is the natural pathway. For organizations operating under NCQA, Joint Commission, or CMS frameworks, different pathways apply. And for organizations navigating multiple accreditations simultaneously, understanding where requirements overlap and where they conflict is essential to avoiding duplicated effort and compliance gaps.
IHS advises clients across all major frameworks. The analysis below draws on 25+ years of direct accreditation consulting experience, including Thomas G. Goddard's tenure as former Chief Operating Officer and General Counsel of URAC.
At a Glance: Framework Comparison
| Framework | Issuing Body | Organization Types | Standalone or Add-On | Evaluation Method | Output |
|---|---|---|---|---|---|
| URAC TOC Designation | URAC | Health plans, case management orgs, CINs, telehealth, home infusion, PCMH | Add-on to existing URAC accreditation | Document review via AccreditNet; look-back period evidence required | URAC Transitions of Care Designation |
| NCQA Care Coordination Standards | NCQA | Health plans, medical groups, PCMHs, accountable care organizations | Embedded in base NCQA accreditation or PCMH recognition | HEDIS data, document review, site visits (for some programs) | Component of NCQA accreditation status or PCMH recognition level |
| Joint Commission Care Transition Standards | The Joint Commission | Hospitals, critical access hospitals, post-acute care facilities | Embedded in Joint Commission hospital or post-acute accreditation | On-site survey including tracer methodology | Component of Joint Commission accreditation |
| CMS Conditions of Participation (CoPs) | Centers for Medicare & Medicaid Services | Medicare/Medicaid-participating hospitals, home health agencies, SNFs | Regulatory requirement (not voluntary accreditation) | State survey agency or deemed status accreditor survey | CMS certification to participate in Medicare/Medicaid |
| ACMA Transitions of Care Standards | American Case Management Association | Hospital-based case managers, social workers, transition coordinators | Professional practice standards (not organizational accreditation) | No formal external review process; self-assessment framework | No formal credential — professional practice reference |
URAC TOC Designation vs. NCQA Care Coordination Standards
URAC TOC Designation
- Explicit, independently awarded designation for transitions of care specifically
- Applies to managed care organizations, case management vendors, CINs, telehealth, home infusion, and PCMH programs
- Five discrete TOC standards with specific operational and documentation requirements
- Evaluated through document review and look-back period evidence — no on-site survey required
- Add-on to existing URAC accreditation; does not require re-credentialing the base program
- Medication reconciliation standard includes formal accountability assignment and communication documentation requirements
- Recognized by health plan contracting teams as a specific market differentiator
NCQA Care Coordination Standards
- No standalone care transitions credential — care coordination is embedded within NCQA Health Plan accreditation, PCMH recognition, or ACO programs
- Applies primarily to health plans and medical practices; less applicable to standalone case management vendors or CINs
- Transitions of care addressed as a component within broader care management standards — not isolated for separate evaluation
- HEDIS measures (e.g., Transitions of Care composite) provide quantitative performance data but are separate from accreditation standards review
- On-site review or hybrid review required for full NCQA Health Plan accreditation
- NCQA PCMH recognition addresses care coordination but through a different standard architecture than URAC's five TOC functions
- NCQA is the dominant framework for commercial and Medicaid health plan accreditation in many markets; URAC and NCQA are sometimes pursued simultaneously
Key distinction: URAC's TOC Designation produces a named, marketable credential specifically for transitions of care. NCQA care coordination performance is embedded within a broader accreditation status — it does not yield a separate TOC credential that can be cited in contracts or RFP responses as a standalone differentiator.
URAC TOC Designation vs. Joint Commission Care Transition Standards
URAC TOC Designation
- Targets managed care organizations, case management vendors, and care coordination programs — not hospitals directly
- Document review process; no on-site survey
- Look-back period evidence requirement is the primary compliance validation mechanism
- Focuses on the coordination infrastructure that manages transitions — the payer/managed care side of the handoff
- Applicable to organizations managing transitions across multiple settings for large patient populations
- Can be pursued by non-hospital entities that are not eligible for Joint Commission accreditation
Joint Commission Care Transition Standards
- Targets hospitals, critical access hospitals, and post-acute care facilities — not managed care organizations or case management vendors
- On-site survey using tracer methodology; surveyors follow individual patients' care paths through the organization
- Embedded in the Joint Commission's broader hospital or post-acute accreditation — not a separate credential
- Focuses on the provider side of the handoff — the hospital's discharge process, care transition planning, and communication to receiving providers
- NPSG.16 (National Patient Safety Goal on care transitions) specifically addresses handoff communication requirements
- The dominant accreditation framework for acute care hospitals in the U.S.; most hospitals hold Joint Commission accreditation
Key distinction: Joint Commission addresses the hospital-side of care transitions. URAC's TOC Designation addresses the managed care and care coordination side. A health plan or case management organization cannot achieve Joint Commission accreditation; a hospital cannot achieve the URAC TOC Designation. These frameworks address different organizations at different points in the care transition.
URAC TOC Designation vs. CMS Conditions of Participation
URAC TOC Designation
- Voluntary accreditation — pursued for market differentiation, contractual positioning, and quality improvement
- No CMS linkage or Medicare/Medicaid participation requirement
- Applies to managed care organizations and care coordination programs, not directly to provider facilities
- Standards are specific to managed care coordination infrastructure — medication reconciliation accountability, transition assessment, care plan continuity, stakeholder communication
- Document review process; no government survey agency involvement
- Pursued when organizations want a named, marketable credential beyond regulatory compliance
CMS Conditions of Participation
- Mandatory regulatory requirement for hospitals, SNFs, home health agencies, and other providers participating in Medicare and Medicaid
- Non-compliance results in loss of Medicare/Medicaid certification — a business-ending consequence for most providers
- Enforced through state survey agencies or deemed-status accreditors (Joint Commission, DNV, ACHC)
- Care transitions addressed in the discharge planning CoPs (42 CFR 482.43) — requires patient-centered discharge planning, post-acute care referral processes, and caregiver education
- Baseline compliance requirement — not a differentiating credential in the market
- Violations can trigger CMS enforcement actions, civil monetary penalties, or exclusion from Medicare/Medicaid
Key distinction: CMS CoPs are the regulatory floor — organizations must comply or lose Medicare/Medicaid participation. The URAC TOC Designation is a voluntary credential that demonstrates performance above that floor. They are not alternatives to each other; they operate in different regulatory spaces and serve different purposes.
When Organizations Pursue Multiple Frameworks Simultaneously
Many organizations operate under two or more of these frameworks at once. Common combinations:
Health Plan Holding Both URAC and NCQA Accreditation
Some health plan markets require or prefer one accreditor over the other; some plans hold both to cover all contracting relationships. When pursuing the URAC TOC Designation in this context, IHS assesses where NCQA care coordination requirements are already satisfied and structures the TOC Designation work to build on existing documentation infrastructure rather than starting from scratch.
Case Management Organization with Joint Commission-Accredited Hospital Partner
A standalone case management organization cannot achieve Joint Commission accreditation, but it may manage transitions for patients discharging from Joint Commission-accredited hospitals. The URAC TOC Designation addresses the case management organization's side of that handoff — the piece that Joint Commission cannot reach. IHS helps organizations articulate this distinction in contracts and RFP responses.
Medicare Advantage Plan Subject to Both CMS Star Ratings and URAC Accreditation
Medicare Advantage plans face simultaneous CMS quality reporting requirements (including Star Ratings measures tied to care transitions) and, in many cases, URAC or NCQA accreditation requirements. The URAC TOC Designation's documentation infrastructure aligns with and supports CMS Star Ratings performance in the Transitions of Care composite measure. IHS maps these overlaps explicitly so clients are not building separate systems for each framework.
Choosing the Right Framework for Your Organization
You are a health plan, case management organization, CIN, telehealth provider, home infusion program, or PCMH organization — and you already hold or are pursuing a URAC base accreditation.
The URAC TOC Designation is the appropriate pathway. It builds on your existing URAC investment and produces a named, marketable credential for care transitions specifically.
You are a health plan that holds NCQA accreditation but not URAC accreditation.
The URAC TOC Designation is not available without a URAC base accreditation. If market or contractual requirements call for a specific care transitions credential, IHS can assess whether URAC base accreditation makes strategic sense for your organization, or whether NCQA's embedded care coordination standards address the requirement.
You are a hospital or post-acute care facility.
The URAC TOC Designation is not designed for hospital or post-acute facility accreditation. Joint Commission care transition standards and CMS CoP discharge planning requirements are the applicable frameworks. IHS does not consult on Joint Commission hospital accreditation.
You are a Medicare Advantage plan facing CMS Star Ratings pressure on care transitions performance.
The URAC TOC Designation's standards infrastructure directly supports Star Ratings performance in the Transitions of Care composite. IHS approaches these engagements with both frameworks in view — ensuring that the documentation and operational structures built for URAC also generate the data CMS measures.
Not Sure Which Framework Applies to Your Organization?
Framework selection is one of the first questions IHS addresses in every discovery session. Thomas G. Goddard, JD, PhD — former Chief Operating Officer and General Counsel of URAC — will assess your organization's accreditation status, contractual environment, and operational starting point and give you a direct recommendation on which pathway makes sense.
Schedule a Free Discovery Session