On July 1, 2025, the updated National Center for Quality Assurance (NCQA) credentialing standards went into effect after much anticipation from payers across the country. These updated standards will raise the bar for payers’ credentialing processes, requiring higher standards for provider data and more oversight of provider eligibility between credentialing cycles.
“At the end of the day, it's really about patient safety and risk mitigation. We're really looking to create that cohesive quality accountability that applies to health plans, health systems, physician groups, commercial CVOs, telehealth companies, really any entity that is accountable and has a network of providers."
—Tsveta Polhemus, AVP, Evaluation Programs, Product Management at NCQA
If you haven’t read the hundreds of pages documenting these changes, you’re not alone. The good news is that Donna Thiel, ProviderTrust’s Chief Compliance Officer, has scoured the document and spoken with NCQA leaders to understand what these changes mean for the industry.
These new standards significantly impact the way most payers approach credentialing, and we’re here to help you unpack what they mean. Here, we’ve highlighted the key areas that affect payers across the country as they adapt to the new standards.
"NCQA sets the guidelines for credentialing, but they don’t tell payers how to achieve those standards. How you elevate your credentialing program will depend on what kind of partner you choose.”
—Donna Thiel, Chief Compliance Officer at ProviderTrust
"Credentialing is the unsung hero of healthcare. As a member, as a patient, I don't realize how much work is being done in the background to keep me safe when I participate in our healthcare system. This matters, and it does make a difference. We know it's hard, and we thank you for your commitment to quality."
—Tsveta Polhemus, AVP, Evaluation Programs, Product Management at NCQA
The credentialing cycle now includes ongoing monthly monitoring.
NCQA now requires credentialing teams to conduct ongoing monitoring for:
- Sanctions
- Complaints
- Adverse actions
These results must be reviewed:
- At least monthly OR
- Within 30 calendar days of a new alert, if the organization subscribes to a monitoring service (e.g., NPDB)
Historically, credentialing has run on a 3-year verification cycle at most payer organizations. After initial credentialing, payers would recredential their providers every few years—leaving obvious gaps in time where payers lack visibility into their providers’ eligibility to provide care.
NCQA also requires that payers take appropriate action when occurrences of poor quality happen, specifically by notifying their Credentialing Committee (or another designated peer-review body) of any occurrences at the next scheduled meeting. The Credentialing Committee will then be responsible for determining the best course of action in each scenario.
"NCQA does not dictate what action is taken [after an incident occurs], but we do want to make sure that the loop is closed appropriately from 'we found something that doesn't meet our criteria' to 'the credentialing committee did something'."
—Tsveta Polhemus, AVP, Evaluation Programs, Product Management at NCQA
Verification windows are shorter to ensure payers are working with more current information.
Under the new NCQA guidelines, payers have less time to act on the provider data they collect. Payers will have to prioritize keeping data fresh to make credentialing decisions in a timely manner without sacrificing quality.
NCQA-Accredited Organizations:
Those that perform the full scope of credentialing services—the timeframe will decrease from 180 days to 120 days.
NCQA-Certified Organizations:
CVOs that verify credentials via a primary source but don’t perform the entire credentialing process—the timeframe will decrease from 120 days to 90 days.
Shorter verification timelines mitigate risk and protect patient safety while also speeding up the time it takes to credential providers so they can start treating patients and payers can start collecting revenue.
While this may be a difficult transition for many payers, the new standards will ultimately uphold NCQA’s mission to improve the quality of healthcare. For ProviderTrust clients, the new standards closely mirror the best practices we’ve recommended for years.
These standards may be difficult for the average payer to meet, but at ProviderTrust, we’ve gone above and beyond these standards for years.
Want to dive deeper into the updated guidelines? Watch our webinar featuring NCQA's Tsveta Polhemus in conversation with Donna Thiel, Chief Compliance Officer at ProviderTrust.
Learn more about how ProviderTrust can help you meet and exceed the updated standards with DynamicNPI, our newest NCQA-certified solution.
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