Changes to the NCQA guidelines will be here quicker than you think. If adhering to their standards is important to your organization, now is the time to evaluate your operations so you’re not left scrambling for a new solution.
Next year’s NCQA standards will make compliance more challenging for organizations still relying on manual credentialing processes, but there’s still time to implement tools and processes that make a difference. Automated credentialing and network monitoring are often overlooked areas of optimization that drive greater collaboration, decision-making, and network growth.
The 2025 Changes to NCQA Credentialing Certification and Health Plan Accreditation
NCQA, the gold standard for healthcare quality, sets the framework for qualifying and determining the legitimacy of practitioners to practice safe care delivery. Their recent release of updates for 2025 include changes to primary source verification timeframes, new language around race and ethnicity, updates to ongoing monitoring requirements, and more.
Below we’ve summarized some of the key implications that will likely have the largest impact on credentialing teams.
Reduced Verification Timeframes
From a credentialing standpoint, the most significant change to NCQA guidelines is the reduction in verification timeframes. Currently, Certified and Accredited organizations must verify a practitioner’s licensure, board certification, history of work, malpractice, state licensing sanctions, and Medicare/Medicaid sanctions. Once verifications are completed, Certified Credentialing Organizations must make a final decision on a practitioner within 120 days, and Accredited Health plans within 180 days. As of July 2025, this verification to credentialing decision timeframe will decrease for both Certified and Accredited organizations.
In addition to the new timeframes, it is now required to verify Medicare and Medicaid exclusions in addition to sanctions.
Ongoing Monitoring
Another significant change coming with the 2025 changes are new requirements and language around how practitioners are monitored in between credentialing events. The significant updates here are for both Certified and Accredited organizations, and include:
- Monitoring frequency is defined as being done at least monthly, and within 30 calendar days.
- License expiration is a requirement for ongoing monitoring
For organizations only monitoring sanctions as they are released, and not including license expiration monitoring, these changes will require a significant lift in effort.
To best understand the entirety of NCQA’s changes for credentialing certification and accreditation in 2025, you can visit NCQA.org to purchase their complete guidelines.
It’s Time to Evaluate Your Credentialing Process
If your team is still relying on manual credentialing processes, these new standards may feel daunting. With timelines becoming faster, it’s no longer sustainable to solve this challenge with more staff–it’s likely you need credentialing automation that empowers your staff to do their best work, and do it efficiently.
You’ll want to evaluate an automated credentialing solution that is interoperable with your CRM, or potentially a switch to an advanced CVO–powered by automation technology, that can handle the speed required to meet new standards. Getting a head start and implementing early is essential to avoid compliance issues, build out any customizations, train staff, and ensure a seamless transition.
Checklist for Choosing the Best Credentialing Software or CVO Services
As healthcare organizations prepare for the new NCQA guidelines and the demands of an expanding provider network, choosing the right credentialing software or Credential Verification Organization (CVO) service becomes critical. The right solution will not only ensure compliance with the stricter timelines but also streamline operations and add efficiency.
Here are the factors to consider when evaluating credentialing software or CVO services:
- Contracted and Average Turnaround Times
Ensure your chosen CVO commits to specific turnaround times to meet the new NCQA standards.
- Automation Capabilities
Verify which aspects of the credentialing process are automated. Request demonstrations to understand the extent of automation and whether or not you can build out other helpful workflows (e.g. provider enrollment or ongoing provider network monitoring).
- NCQA Certification and Compliance
Confirm that the CVO is certified by NCQA, or that the chosen software easily enables compliance of the latest regulations.
- Provider Type Support
Determine the provider types that your solution can support with primary source verifications and reporting. After all, NCQA plans to expand provider-type verifications, furthering demand for integrated primary sources.
- Primary Source Verifications
With license expirations becoming a requirement for monthly monitoring, you’ll want to ensure that these sources can be verified automatically without human intervention.
- Up-to-date Provider Directory
Assess how the solution helps maintain an accurate and current provider directory, and the potential for reducing the lift and duplicative efforts of provider onboarding and ongoing verifications.
- Customization and Configurability
Explore the levels of customization and configurability available to tailor the solution to your organization’s specific needs (e.g. reporting, real-time compliance alerts, state and specialty coverage, etc.).
- Pre-configured vs. On-demand Reporting
Review the types of pre-configured reports and the flexibility to generate on-demand reports as needed. Ask for samples of report types that can be preconfigured, plus the custom reporting your team can pull ad hoc.
Embrace Credentialing Automation to Win in 2025
Manual credentialing processes and backlogged CVOs could reach their breaking point in 2025, making now the time to invest in scalable, sustainable credentialing solutions.
By partnering with the right credentialing automation software or CVO, you can transform credentialing from a compliance bottleneck into a competitive advantage. After all, better and faster medical credentialing is a proven lever for growth.
Ready to see how Verifiable’s credentialing and monitoring solution will set you up for 2025 (and beyond) in no time? Book a demo today.
