NCQA Health Plan Accreditation: What Health Plan leaders need to do as you plan for 2027 changes

July 1, 2026, isn’t just a date to circle on the calendar for NCQA teams.  It’s an operational milestone.  The 2026 NCQA Health Plan Accreditation standards introduced changes that will require operational and technical redesign, not just policy updates.  Some of these changes are tied to federal regulations already in effect such as Inter-Operability and Prior Authorization Final Rule (CMS-0057-F) or CMS focus like Provider Directory Accuracy.

2026 NCQA Standards: Six Key Changes

  1. Non-urgent preservice UM (Utilization Management) decisions must be completed in seven (7) calendar days. This is a must pass element that requires workflow redesign.
  2. The UM Program Structure (UM1) has significant changes, including requiring more rigorous committee oversight (UM1, Element G), use of data for improvement activities with documented improvement outcomes (UM1, Element H). This requires change in governance, business process, oversight and availability of data to identify improvement needs and measure the effectiveness of interventions.
  3. UM criteria must now be available to practitioners at the point of care (UM2, Element B). For many plans, this requires building technical capabilities with their vendor partners and partnership between the Quality, Provider Network and technical teams.
  4. PHM (Population Health Management) data sharing will be a standalone scored element (PHM 3, Element A). QI gains a data element specifically for behavioral health data sharing (QI 2, Element C). This requires building technical capabilities and a structured data-sharing process with bidirectional data exchange capabilities.
  5. NET (Network) and CR (Credentialing) are no longer periodic functions. They now have continuous monitoring requirements and annual attestation for accuracy.
  6. PHM Standards now requires quantifiable information on payments tied to alternative payment models (APM) (PHM3, Element C). This requires workflow changes, technical build and contract review with vendors to be compliant.

2027 Survey Readiness: Six Areas of Focus
(July 1, 2026, to June 30, 2027)

  1. Data Strategy: Bi-Directional API (application programming interface) and use of industry-developed, consensus-based standards (ex: FHIR API) designed to support rigorous data collection and business applications.
    1. Does your plan have an automated, bi-directional data exchange capabilities for physical and behavioral health to support business functions and use of alternative payment models (APM)? Timeline: Immediately, some Elements have a 24-month look back period.
  2. UM Program Structure: The shift in the UM Program and Governance is subtle, yet it reframes UM from file review and documentation to add a continuous process improvement function to evidence compliance.
    1. Does your UM Program Description include a rigorous UM Committee oversight process including a process for identification, implementation and reassessment of improvement initiatives? Timeline: Q1 2026
    2. Are you collecting and using the six (6) key metrics for UM monitoring (denial rates, denial reasons, approval rates, percentage of prior-authorizations, appeal overturn rates, and timeliness)? Timeline: Q3 2026 or earlier.
  3. Clinical Criteria for UM Decisions (UM2, Element B):
    1. Can your providers access UM criteria readily via the provider portal, clinical decision support tool or API at the point of care? Timeline: end of Q3 2026 or sooner if an API has to be built.
  4. Oversight of non-NCQA accredited delegates (UM12, Element E).
    1. Does your process include documentation to evidence annual audits, including findings and any corrective action plan (CAP) and the completion of the CAP? Timeline: Q1 2026 included in the 2026 UM Program Description
  5. Provider Directory Accuracy Assessment (NET5, Element C).
    1. Is there a process in place to verify accuracy of the directory every 6 months, and updates to changes within 30-days for MA plans? Timeline: Q3 2026
  6. Behavioral Health and HEDIS measures (QI2, Element C)
    1. Can the plan show evidence of at least one contract with a behavioral health organization that contains bi-directional data to support at least one of seven BH HEDIS measures? Timeline: Q3 2026

BluePeak can help!

If you answered yes to all the above, then your Plan is in great shape. If you answered no, or are not sure, then Blue Peak Advisors can support you in aligning clinical and operational protocols to the 2026 NCQA Health Plan Accreditation changes.

Contact Us today!

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