Critical Credentialing Updates in California (2025 - 2028)
Credentialing Standardization & Timeline Reforms
Starting in 2028, California health plans must adopt the latest CAQH standardized credentialing form for both credentialing and recredentialing. Plans may request only minimal additional information to confirm or clarify what is already included in CAQH.
Providers are responsible for submitting and maintaining accurate credentialing data in CAQH in accordance with these standards.
Why it matters?
- Creates smoother credentialing across plans.
- Reduces repetitive paperwork.
- Plans must respond faster and limit requests beyond CAQH data.
Providers who fail to maintain updated CAQH profiles may still experience repeat requests and slower decisions.
This is a major simplification effort — but only if CAQH data is kept current.
NCQA Credentialing Standard Overhaul (2025)
The 2025 NCQA updates, considered among the most significant in decades, introduce:
- Notification of provider decisions within 30 calendar days (instead of older 60+ day expectations).
- Expanded requirements for policies addressing sanctions, complaints, and ongoing monitoring.
- Updated practitioner application expectations and review timelines.
Provider impact
- Faster turnaround expectations — beneficial if teams are prepared.
- Greater need for structured and detailed documentation.
Credentialing departments should align policies and procedures with these standards well before mid-2026.
Legislative Actions Affecting Credentialing & Provider Networks
California's 2025-26 legislative direction reinforces upcoming rules that will require insurers to:
- Use a standardized credentialing form by 2026/2027.
- Minimize collateral or duplicative information requests.
- Collect only essential data.
Provider takeaway
Administrative burden will shift away from repetitive payer forms. Strong coordination between credentialing and compliance functions will become a competitive advantage.
Medi-Cal Provider Training & Credentialing Attestation
Providers new to Medi-Cal must complete mandatory training and sign attestation documentation before they can be fully credentialed.
Why this is important?
Failure to complete attestations can result in contract or enrollment holds with Medi-Cal plans.
This is especially relevant for practices that:
- Add or remove affiliations
- Update demographics
- Expand service lines
California-Specific Professional Credential Integrity Concerns
Recent reports of credential misrepresentation among certain healthcare professionals in California have triggered increased scrutiny, compliance alerts, and potential regulatory exposure.
Providers should:
- Verify that certifications and qualifications are accurate before clinical engagement.
- Implement internal quality checks within credentialing systems.
Broader Healthcare Domain Buzz - What Providers Are Discussing
AI + Healthcare Transformation
Industry analysts predict a massive migration of healthcare spending toward digital, AI-enabled care models, including virtual care, automation, decision support, and integrated consumer platforms.
Provider impact
Credentialing will increasingly rely on technology integration and automation.
Practices using real-time tracking, digital documentation management, and AI-assisted workflows will be better positioned to meet compliance timelines.
JPM Healthcare Conference: Innovation & Investment Signals
The annual JPM gathering remains a strong indicator of where healthcare investment is heading. Common themes:
- Digital health acceleration
- AI and operational automation
- Consumer-centric, virtual-first delivery
Expanding Regulatory & Compliance Expectations
Ongoing updates to California privacy requirements and growing oversight across healthcare intermediaries signal a tightening regulatory environment.
Key risk areas
- Protection of credentialing and provider data
- Expanded reporting and disclosure expectations
The Provider Reality: Credentialing Bottlenecks & Revenue Impact
Feedback from providers continues to show:
- Credentialing timelines often stretch 90 - 120+ days.
- Missing CAQH attestations and outdated files are frequent delay drivers.
- Groups using tracking systems, proactive renewals, or external support report faster approvals and fewer denials.
Business insight: Credentialing is no longer a back-office task — it directly influences revenue speed, contracting leverage, and compliance risk.
Strategic Professional Actions for Providers & Practices
Update & Automate Your Credentialing Operations
- Keep CAQH information continuously updated.
- Respond quickly to verification outreach.
- Track payer timelines and submit early.
- Use dashboards, alerts, and status monitoring tools.
Prepare for Compliance Milestones
- 2026: Transition toward standardized forms begins.
- 2028: Full health plan compliance with streamlined mandates.
- NCQA updates should already be reflected in internal policies.
Strengthen Payor Relationships
- Assign dedicated contacts for each plan.
- Maintain documentation of communications and submissions.
Connect Credentialing to the Revenue Cycle
Effective credentialing supports:
- Faster reimbursement
- Reduced denials
- Stronger negotiating positions
Summary - Why This Matters Now
Credentialing in California is rapidly becoming a compliance-driven competitive differentiator. With legislative standardization, updated NCQA expectations, and industry momentum toward automation and AI, providers that modernize credentialing workflows will reduce risk, limit denials, and accelerate revenue realization.
