Effective July 1, 2025
The National Committee for Quality Assurance (NCQA) has introduced key changes to its credentialing standards, set to take effect from July 1, 2025. These updates will impact the way organizations approach credentialing, compliance, and accreditation. Here’s what you need to know:
Consolidation of Credentialing Programs
NCQA is simplifying its credentialing process by merging the accreditation and Certified Verification Organization (CVO) certification programs into one. While this streamlines the process, it also requires closer alignment of organizational policies and procedures.Revised Verification Timelines
NCQA is shortening verification timelines to improve efficiency:Licensure verification will move from 180 days to 120 days.
Work history verifications will decrease from 365 days to 120 days.
Organizations must adjust their processes to ensure timely completion within these updated windows.
New Interim Survey Option
NCQA now offers an interim survey to review organizational policies and procedures, providing an 18-month grace period to address any gaps before full accreditation. This option helps ease the transition but requires careful planning and preparation.Provider Demographic Data Updates
Organizations must now collect race, ethnicity, and language data from credentialing applicants. These fields must be available for providers to fill out, but they remain optional.Stricter Sanctions Monitoring Requirements
The new regulations mandate that organizations obtain exclusion information from all state sources for Medicaid providers, and ensure compliance with Medicare’s exclusion database.
Impact on Payers: Key Challenges Ahead
With these updates, payer organizations face several challenges:
Shortened timelines mean faster data collection and reporting are necessary. Manual processes will no longer be sufficient.
Increased data complexity with the inclusion of race, ethnicity, and language fields will require systems and processes that are both robust and standardized.
Operational burdens include managing the interim survey and addressing any gaps before full accreditation.
Compliance risks include potential penalties and reputational damage for non-compliance or delays in accreditation.
These changes highlight the growing complexity of the regulatory landscape. To remain competitive and compliant, payer organizations will need to adapt their credentialing systems and processes to meet these new requirements.