Compliance confidence: How to prepare for upcoming changes to NCQA license monitoring requirements

The growing credentialing burden and NCQA license monitoring requirements

With credentialing, if you’re not ahead of the game, it’s going to bite you where it hurts—right in the bottom line. 

Credentialing is a fundamental process in healthcare, ensuring patient safety, regulatory compliance, and trust between patients, providers and health plans. However, outdated credentialing processes and evolving NCQA license monitoring requirements are adding to the administrative burden.

When a provider like Dr. John Smith finishes residency, he often contracts and enrolls with multiple health plans. Each plan conducts its own credentialing process, often resulting in different re-credentialing dates.

For organizations—especially those managing large provider networks—this duplicative and inefficient approach strains resources, leading to delays in patient care and increased financial risks.

A recent industry survey by Medallion found 33% of respondents reported credentialing delays between 30 and 45 days. With providers in networks with up to 19 health plans, redundant processes create inefficiencies that slow down compliance efforts and drive up costs.

As regulatory requirements evolve, these inefficiencies become even more costly, particularly with NCQA’s stricter license monitoring requirements approaching. Payer and healthcare organizations must take a proactive approach to reducing administrative redundancies and ensuring compliance.

One key area of focus? Provider license monitoring.

Why NCQA license monitoring requirements matters

Credentialing verifies that a provider is who they claim to be, but licensure is the official validation that they meet all necessary qualifications to practice in a specific state. According to the Association of State and Territorial Health Officials, licensing is "the formal recognition by a regulatory agency or body that a person has passed all the qualifications needed to practice that profession in that state."

Essentially, a provider’s license serves as a stamp of approval, ensuring they are qualified to deliver safe, effective patient care. Because provider licensure is the foundation of high-quality healthcare, payer organizations, provider groups and health systems must diligently monitor licensure status to stay compliant with NCQA license monitoring requirements.

A lapse in monitoring can have serious consequences, including: 

• Financial penalties – Providers may face lapsed licensure fees and reinstatement costs.
• Temporary suspension from practice – An expired license means a provider is legally barred from treating patients.
• Recredentialing delays – An expired license can stall provider enrollment, affecting network participation and claims processing.

Why it matters: Staying ahead of licensure expirations is crucial for compliance, operational stability, and ensuring uninterrupted patient care. With stricter NCQA license monitoring requirements taking effect, organizations must take a proactive approach to tracking and verifying provider credentials in real-time.

How are NCQA license monitoring requirements changing in 2025?

One of the most significant regulatory updates is NCQA’s revised license monitoring requirements under CR5, Element A, Factor 3, effective July 1, 2025. These changes introduce stricter compliance expectations for payers, providers, and healthcare organizations, emphasizing proactive license tracking and oversight.

Upcoming changes: 

• Monthly provider licensure reviews – Organizations must verify provider licenses on a recurring basis.
• 30-day response window – Expired licenses must be addressed within a strict 30-day timeframe to avoid compliance risks.

What this means for healthcare organizations:

For payers:

Compliance failures can lead to operational disruptions, reputational harm, and potential regulatory penalties. Ensuring a verified provider network is essential for maintaining trust with regulators, providers, and members.

For provider groups:

Proactive license management reduces administrative burdens, ensures uninterrupted patient care, and protects organizational standing under evolving NCQA guidelines.

For health systems:

With diverse provider networks, healthcare organizations must implement real-time licensure tracking to minimize compliance risks and prevent disruptions to patient care.

As NCQA standards evolve, organizations should regularly track updates on NCQA’s website for the latest compliance requirements.

Risks and challenges with provider license monitoring

Maintaining compliance with provider licensure requirements requires continuous oversight across multiple sources, including state licensing boards, federal databases and exclusion lists.

Effective monitoring ensures that provider networks remain compliant and operational, but many organizations face challenges in achieving seamless license monitoring.

• Manual processes are outdated – Despite increasing compliance demands, 58% of healthcare teams still rely on spreadsheets and disconnected databases (teams report using two or more tools to manage the work,) which are no longer sustainable. This reliance creates administrative strain and increases the risk of missed expirations.
• Inconsistent reporting standards – Licensing requirements vary across states, making centralized compliance oversight difficult for organizations managing multi-state provider networks.
• Lack of real-time alerts – Without automated alerts and continuous monitoring, compliance teams may fail to act quickly on expired credentials or provider sanctions, exposing organizations to financial penalties and operational disruptions.

Why it matters:The real challenge is how manual processes make it nearly impossible to get ahead of these growing compliance demands. Failing to monitor provider licenses effectively can lead to severe consequences, including regulatory non-compliance and reputational risks.

The National Practitioner Data Bank (NPDB) serves as a critical resource for tracking provider sanctions and disciplinary actions, yet many organizations lack streamlined processes to integrate such data into their compliance workflows.

Without automated alerts and real-time visibility, compliance teams may fail to act quickly on expired credentials or new provider sanctions.

How to prepare for NCQA’s 2025 license monitoring requirements changes

Given the heightened oversight, and potential risks for not keeping up, organizations must take a proactive approach to ensure compliance with NCQA’s updated requirements. To remain compliant, healthcare organizations must monitor provider networks against NCQA-required sources, while also considering additional sources based on delegation agreements with specific health plans.

Relying on manual or outdated network monitoring methods can make it difficult to meet NCQA’s recommended monitoring frequency, increasing the risk of compliance gaps and penalties. With Medallion’s automated, real-time monitoring, organizations can stay ahead of evolving NCQA requirements and maintain continuous compliance with confidence.

Below are five essential steps to prepare:

Stay ahead of NCQA compliance with automated, ongoing monitoring

To remain compliant, healthcare organizations must monitor provider networks against NCQA-required sources, while also considering additional sources based on delegation agreements with specific health plans.

Relying on manual or outdated network monitoring methods can make it difficult to meet NCQA’s recommended monitoring frequency, increasing the risk of compliance gaps and penalties. With Medallion’s automated, real-time monitoring, organizations can stay ahead of evolving NCQA requirements and maintain continuous compliance with confidence.

Explore how Medallion’s technology ensures faster, more frequent monitoring that keeps your organization compliant—without the administrative burden.

Why Medallion?

Whether you’re a payer safeguarding your network, a provider group optimizing operations, or a health system managing a complex workforce, Medallion equips you to meet NCQA’s updated standards with efficiency and assurance.

✅ Streamlined monitoring: Automated tracking reduces the burden of manual reviews.

✅ Proactive notifications: Tiered alerts prevent lapses before they occur.

✅ Centralized compliance oversight: A unified dashboard offers full visibility into provider licensure status.

With Medallion’s 24/7 monitoring, organizations can:

• Ensure compliance while minimizing monitoring costs.
• Improve provider data accuracy with real-time updates.
• Enhance network visibility with instant alerts for sanctioned/excluded providers.

Key monitoring features include continuous provider tracking and rich visibility across SAM, OIG, NPDB, Medicare Opt-Out, and Medicaid exclusions, and advanced compliance oversight for State Licenses, DEA Licenses, CSR Licenses, OFAC, and more.

Tailored compliance solutions for every organization:

The Medallion advantage in NCQA compliance

As the healthcare regulatory landscape evolves, healthcare organizations must keep pace by integrating smarter compliance solutions into their operations. Adopting technology that meets NCQA’s 30-day alert window and streamlines license monitoring is a critical step. The transition may require initial investments in both time and resources, but the payoff is a resilient, compliant network that protects your organization from potential operational disruptions and reputational harm.

In today’s environment, compliance confidence isn’t just a regulatory checkbox—it’s a strategic asset. Healthcare organizations that invest in proactive and automated  license monitoring solutions position themselves to navigate these changes smoothly, ensuring ongoing trust with providers, members, and regulatory bodies alike.

For more insights on effective compliance strategies, check out resources from theNational Association of Insurance Commissioners (NAIC) andHealthcare Financial Management Association (HFMA).

Visit our site to explore our collection of resources including how to turn compliance into a win (not a risk) and new ideas to transform your organization's credentialing process. Follow us on social media to stay updated on our latest product updates and upcoming events.

Ensure seamless compliance and risk-free credentialing with automated, real-time license monitoring. See how your compliance measures up—speak with our experts or book a demo to see Medallion in action.