NCQA PCMH 2025 annual reporting: Standards and guidelines

For practices recognized under the National Committee for Quality Assurance’s (NCQA) Patient-Centered Medical Home (PCMH) model, understanding and meeting the NCQA PCMH 2025 annual reporting requirements is critical to sustaining recognition. 

NCQA continues to refine its NCQA PCMH standards and guidelines, emphasizing team structure, care continuity and data integrity. Here’s what your practice needs to do to stay compliant and ensure a smooth reporting process. This blog is a continuation of our piece back in July 2024, which listed three updates to NCQA PCMH's 2025 annual reporting requirements.

What is NCQA PCMH? 

The NCQA Patient-Centered Medical Home (PCMH) is a model of care that emphasizes care coordination, patient engagement and continuous quality improvement. The PCMH framework is designed to improve healthcare outcomes by fostering strong patient-provider relationships and enhancing team-based care. 

Since its inception, the NCQA PCMH program has evolved to ensure practices meet modern healthcare challenges, including the integration of behavioral health, addressing social determinants of health and leveraging data for improved decision-making. The NCQA PCMH standards and guidelines are updated regularly to reflect these advancements, ensuring that practices provide high-quality, patient-centered care. 

For practices recognized under the NCQA PCMH model, understanding and meeting the NCQA PCMH 2025 annual reporting requirements is critical to sustaining recognition. NCQA continues to refine its NCQA PCMH standards and guidelines, emphasizing team structure, care continuity and data integrity. Here’s what your practice needs to do to stay compliant and ensure a smooth reporting process. 

Comparison of 2024 vs. 2025 updates 

Key changes in NCQA PCMH reporting for 2025 

NCQA introduced several updates for NCQA PCMH 2025 annual reporting requirements. 

eCQM reporting adjustments 

Practices must report eight electronic clinical quality measures per site for the period Jan. 1, 2024 - Dec. 31, 2024, using numerator and denominator format. Notable changes: 

• New preventive care measure added: Sexually transmitted infection (STI) testing for people with HIV under preventive care. 

• Removed measure: Adult major depressive disorder (MDD) treatment from behavioral health. 

• New chronic/acute condition measures: HIV viral suppression. Pediatric sites can still report on custom measures, as the library lacks pediatric-specific reporting. 

• Immunization reporting: Flu and pneumonia have been removed from mandatory reporting for adult practices. But they can be used as a customized measure, along with any other measure that the practice deems appropriate. 

• Immunizations: Only Childhood Immunization Status (CIS) is mandatory for pediatric or family medicine sites.  

• QI reporting: Annual reporting 2025 also requires an additional attestation to ensure the integrity of the data provided by the practice. 
  
  

Care plan audit expectations 

• Increased focus on comprehensive care plans, ensuring that problems, medications, goals and self-management components are documented; specifically:  

• problems; 

• medications; 

• return date; 

• expected outcomes; 

• goals and preferences; 

• barriers and solutions; and 

• patient-owned self-management.  

• Along with the components mentioned above, the care plans are current and provided to the patient. 

• Practices must provide three thorough examples of care plans from different categories. 
  
  

Diversity data reporting 

• Practices must submit a 2024 diversity report, breaking down patient demographics by race, ethnicity, language, gender identity* and sexual orientation for patients age 18 and older. 

Performance expectations 

• Measures scoring below 80% adherence require an explanation and an action plan. The action plan should be innovative and tailored to PCMH criteria, demonstrating a clear path to improvement. 

 
These updates reinforce NCQA’s commitment to data integrity, care coordination and patient-centered outcomes, making it crucial for practices to stay informed and prepared. 

Key annual reporting requirements 

Timely submission and policy updates 

• Practices must submit their annual reports on or before their reporting date to maintain NCQA PCMH accreditation. 

• Annually review and update all policies and procedures to reflect current workflows, documentation standards and ownership roles. 

• If audited, NCQA can request documentation for any PCMH criteria, holding practices accountable for compliance with their documented policies. 

NCQA PCMH reporting focus areas 

To fulfill annual reporting requirements for PCMH recognition, NCQA will emphasize specific criteria within each PCMH reporting category: 

1. Team-based care 

Clearly define team roles, responsibilities and leadership within your practice. 

2. Access and continuity 

Ensure timely and documented clinical advice continuity, aligning with practice policy requirements. 

3. Care management and support 

• Maintain a patient panel that includes at least three out of five care management categories: 

• behavioral health; 

• complex/chronic needs; 

• high cost/utilization; 

• social determinants of health; and 

• referral-based care. 

• Meet a 75% compliance rate on care plan audits of at least 30 consecutively seen patients. The care plan must include problems, medications, goals, patient preferences, barriers/solutions, self-management, expected outcomes and a follow-up visit date. Each site must provide three detailed care plan examples from three distinct categories. 
  
  

4. Care coordination 

Provide evidence of follow-up care for patients discharged from an emergency department (ED) or inpatient (IP) stay. 

5. Knowing and Managing Your Patients (KM) 

Submit a 2024 diversity report with a breakdown of patient demographics, including: 

race, ethnicity, language and sexual orientation (for patients 18+). 

One additional measure relevant to a vulnerable/diverse population within the practice. 

6. Performance measurement and quality improvement (QI) 

Practices must attest to data integrity and be prepared to verify sources and accuracy. 

NCQA reserves the right to review data sources and integrity at any time. 

Conquer NCQA PCMH 2025 standards and guidelines  

Navigating NCQA PCMH certification and annual reporting can be complex, but DataGen’s Medical Practice Consulting solution can help streamline the process, making it easier to meet PCMH annual reporting requirements to sustain recognition.  

Our experts provide tailored guidance on PCMH reporting requirements, policy updates and workflow optimization to ensure compliance with NCQA PCMH 2025 annual reporting requirements.  

With a data-driven approach, DataGen helps practices maintain their NCQA PCMH-recognized practice status by ensuring accurate data submission, optimizing care management workflows and preparing comprehensive documentation for audits.  

Learn more about how DataGen’s Medical Practice Consulting can support your practice in achieving and sustaining NCQA PCMH accreditation. Start preparing now to ensure a seamless NCQA PCMH annual reporting process for 2025! 

*This has been frozen, i.e., hidden, until further notice.