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NCQA guideline updates go into effect July 1, 2025 — is your organization prepared?
Our latest webinar covered exactly what you need to know, including what’s changing, what’s at stake for health plans and provider organizations, and how you can take action and achieve compliance in 2025 and beyond.
We wrapped our session with a Q&A featuring insight from Verifiable Senior Solutions Consultant Jocelyne Wood and Principal Solutions Engineer BJ Bowen.
Questions and answers have been edited and condensed for clarity.
What is changing in the provider demographics space, specifically regarding ethnicity and language?
NCQA is encouraging health plans and provider groups to maintain this information, including race, ethnicity, and spoken language. This aligns with their broader health and equality initiative and aims to better match patients with providers who either share or better understand their cultural background and linguistic preferences.
Does NCQA require copies of certain documents including copy of license or malpractice?
NCQA doesn’t specify that they need copies of certain things beyond your license verification. While not an NCQA requirement, Verifiable does work with clients where this is a requirement from some of the payers they work with; Verifiable works closely with clients in those instances to make sure they have everything they need.
Can you go over the credentialing verification timeline decreases?
Health plans must now complete packets within 120 days of submission instead of 180 days; CVOs must now complete credentialing within 90 days instead of 120 days.
How does the 120 days for recredentiaing work? Does the 120 day countdown start from when organizations receive the application to when they’re fully credentialed?
For initial credentialing, dates start at submission, which involves the pulling of a clean, updated application from CAQH or the returning/filling out of our onboarding form. That starts our clock, and from there we have 120 days — or 90 days, depending on the client — for Verifiable to finish our process, or, if you’re a platform, for you to finish your committee process. Those timelines are now the industry standard; Verifiable’s typical turnaround time is within three days.
To ensure recredentialing is completed on time — 3 years from the initial credentialing approval — Verifiable recommends sending providers notice of when recredentialing is due and requesting an updated application and attestation 120 days in advance of the recredentialing date. Verifiable’s software includes built-in email workflows to notify providers of recredentialing 120 days in advance — although this timeframe is configurable based on your organization.
How will reporting and dashboard capabilities augment to support the new requirements and how will systems control reporting from Verifiable’s CVO change to support compliance?
Verifiable includes standard reports that use Salesforce’s native reporting, which is a very powerful tool. One of the benefits there is that the reports basically mean that you don’t have to build those from scratch (although you can generally build anything you need within Salesforce reporting). Verifiable offers out-of-the-box configurability to meet those requirements. For users of Verifiable’s CVO services, when it comes to information integrity (the new name for “systems controls”), you’re going to work closely with your account manager, who will provide you with reporting as requested.
Is NCQA adding state sanctions in addition to SAM?
Organizations are required to verify state sanctions, restrictions on licensure and limitations of scope of practice for all states where a practitioner has provided care in the past five years.
Will the frequency in the Salesforce platform be adjusted to meet the new timeline for SAM?
Verifiable has the ability, from a technical standpoint, to query any of those sources back to Salesforce on whatever frequency is required; we’re easily able to update that frequency based on all changing NCQA standards. If you specifically have to operate under more stringent standards, we can accommodate that as well — our default is to use NCQA guidelines as our North Star.
How often are OIG's monitored?
Verifiable can complete OIG monitoring on either a daily or monthly basis, depending on what’s required.
Does NCQA require death master to be viewed?
It is not a requirement, but it is an industry best practice.
If Verifiable created a custom onboarding form, is it automatically updated to meet the new NCQA requirements or do we need to put in a request to update? For example, do we need to reach out to support if we want new ethnicity information to be added to an onboarding application?
For any technical configurations, please connect with your Verifiable account manager; we always look to avoid making any changes without your approval!
Is there a breakdown of all the changes in one sheet?
Please reference our recently released NCQA Credentialing Standards guide.
Will you be providing us with the NCQA 2025 Policy and Procedures Handbook? Or will we need to purchase this from NCQA separately?
You can place orders for NCQA’s entire inventory of publications, databases, newsletters, and other products in their online store.
Need more information about changing NCQA guidelines? Watch the full webinar on-demand now.
