Policy Changes, New Requirements, and How to Prepare
Estimated read time: 5 minutes

If you read Part 1, you know the foundation has changed—six modular Evaluation Options, a new scoring model, and the complete retirement of UMA 2. If you haven’t read it yet, start there. This blog assumes you’re working from that baseline.

Part 2 is where we get into the work. What requirements moved—and where did they land? What’s genuinely new with no 2025 equivalent? And which changes have hard deadlines that require action now, not when your next survey cycle is already underway?

Let’s get into it.

What Moved: The Reorganization Behind the New Numbers

Here’s the first thing to understand: most of what’s in the 2026 UMA standards is not new. It’s reorganized.

The 2026 framework takes a line-of-business approach. All requirements related to a particular type of decision are now grouped together in a single evaluation option, rather than spread across functional standards that cut across service lines. If you’ve spent years knowing these standards by number and name, be prepared—this is going to require some re-memorization.

Here’s the key mapping:

• Quality improvement and privacy requirements — previously in UMA 1 and UMA 3 — have moved into the UM Core Standards that apply universally to all organizations, regardless of which Evaluation Options they pursue. The requirements still exist. They’ve just moved tiers.
• Decision standards UMA 1, 2, and 3 (Non-Behavioral Health, Behavioral Health, and Pharmacy Decisions) each consolidate six requirements for their service line: practitioner review, notification, relevant information, peer-to-peer discussion, written notification of denials, and written notification of appeal rights. This content traces back to prior UM 4, 5, 6, and 7.
• Pharmaceutical management content from UM 11 is now UMA 4.
• Appeals content from UM 8 and 9 is now UMA 5.
• Recommendations content is UMA 6.
• UM 10 is no longer in existence. New Technology is typically the responsibility of the health plans the UM organizations service, so removal made so much sense.

The standard numbers are new. Most of the requirements are familiar. Your job right now is to make sure your documentation tracking reflects the new numbering—because element names and reference numbers have changed even where the underlying substance has not.

What Is Genuinely New: Four Areas With No 2025 Predecessor

This is the part that requires building, not just updating. NCQA has introduced substantive new requirements that organizations will need to construct compliance programs around from scratch.

UM Rates Data Collection (UM 3B–E)

New data collection elements require organizations to track and report UM rates for each applicable Evaluation Option: overall approval rates, overall denial rates, timeliness of notifications, overall appeal rates, and appeal overturn rates.

NCQA has been explicit that this data will not be used to score organizations, compare them against peers, or appear on public Report Cards. It’s collected to support understanding of utilization, quality, and access patterns. That’s reassuring. What’s not reassuring? If you don’t currently capture this data systematically, you need to build that capability before your next survey.

Consulting Tip: Review the requirements carefully for Elements B, C, and D regarding where to count partial approvals and partial denials. The answer: they go in both categories. Make sure your tracking reflects that.

Evaluation of UM Data and UM Committee (UM 3F, G)

Collecting the data isn’t enough. A new element requires organizations to actually analyze what they gather—evaluating each rate, drawing conclusions, and documenting the reasons behind denial patterns. A number on a spreadsheet is not compliance.

A companion element goes one step further: an accountable committee must formally take responsibility for reviewing this data and recommending improvement actions. You may use an existing QI or standing committee, as long as it formally assumes the UM oversight function and that role is documented. Don’t assume your current committee structure covers this automatically. Whatever committee is responsible, make sure to include this new responsibility to the charter and the agendas.

Implementation of Improvement Actions (UM 3H)

This is the completion of the quality improvement loop of measure, analyze, act. Collect the data. Evaluate it. Bring it to committee. Then—and this is the part that trips organizations up—actually act on what the committee recommends.

Evidence of implementation is required during the look-back period. Not planning. Not intent. Implementation. The goal is for organizations to use UM data to identify inefficiencies, delays, and policy gaps that would improve timely authorization of clinically appropriate care. Close the loop or expect the finding.

Policy Changes That Require Action

Several 2026 changes are formal policy modifications—not clarifications. Organizations must implement these within 90 calendar days of the Interactive Review Tool release date, unless a specific effective date applies. Don’t file these away. Put them on the action list.

Notification Timeframes Tightened for Medicaid and Medicare

The notification timeframe for nonurgent Medicaid and Medicare request decisions has been revised from 14 calendar days to 7 calendar days.

The effective date matters: this requirement applies to surveys conducted on or after July 1, 2026. That clock is ticking.

This affects notification elements across UMA 1, UMA 2, and UMA 3. Audit your current Medicaid and Medicare notification turnaround times against the new 7-day benchmark now. Address gaps in policies, procedures, and operational capacity well before that date—not in June.

Pharmaceutical Update Communications: 30 Days in Advance

Under 2025, organizations communicated pharmaceutical restrictions, preferences, and formulary information annually and after updates were made. Under 2026, that communication must happen annually and within 30 calendar days in advance of updates—not after.

This is a shift from reactive to proactive communication, aligning with CMS Part D requirements. Establish internal triggers that prompt member and prescriber communication before formulary changes take effect. If your current process waits for the change to happen first, it needs to be redesigned.

New Factor 7 in Appeal Notifications: IRO Cost

⚠ ACTION REQUIRED — Update Denial and Appeal Letter Templates UMA 5 Element E now includes a new Factor 7: if the next level of appeal is independent external review, the notification must state that members are not required to bear the costs of the IRO—unless state law mandates a filing fee. If state law requires a fee, provide the state’s required language. Importantly: if this notice appears in the denial letter rather than the appeal letter, the denial letter satisfies Factor 7.

This is a template fix. It’s not complicated—but it has to happen. Pull your denial and appeal letter templates now and make the update.

UM Criteria Must Be Electronically Accessible
The 2026 standards now require organizations to make UM decision criteria available electronically—through an EHR, a portal, or a website—at the point of care.

Electronic access was not explicitly mandated under prior standards. Organizations are not required to distribute full proprietary criteria if restricted by licensing agreements, but individual criteria must be electronically accessible promptly upon request.

Acceptable evidence includes system reports or screenshots showing how criteria can be accessed at the point of care. If your organization currently relies solely on paper-based or request-based distribution, that approach needs to change.

A word of candor here: for the parallel requirement in the health plan standards, this one is generating considerable operational distress. It’s worth getting ahead of it early.

What Organizations Should Do Now
A passive read of the new standards is not sufficient preparation. Here are the four areas that need active attention—in order.

1. Confirm which Evaluation Options apply to your organization. This drives your next survey application and determines which UMA standards govern your work. Then remap your existing compliance documentation to the new standard and element numbering, paying particular attention to what moved from UMA to UM Core.
2. Build the UM rates data infrastructure if it doesn’t already exist. This is the most time-sensitive operational task. The data collection, UM Committee, and improvement action elements all require documentation workflows that may not yet be in place.
3. Address the three hard-deadline policy changes. Update notification policies and operational processes for the 7-day Medicaid/Medicare timeframe before July 2026. Establish advance-notice protocols for formulary updates. Revise denial and appeal letter templates to incorporate the IRO cost language.
4. Verify UM criteria are accessible electronically at the point of care and prepare screenshots or system reports as evidence before your next survey.

Organizations that move through these four areas methodically—governance first, then new requirements, then policy updates—will be well positioned for the new survey cycle without last-minute scrambles.

How MHR Can Help
The 2026 UM Accreditation changes are substantial, and the window to prepare is narrower than it looks. MHR consultants are deeply familiar with both the 2025 and 2026 frameworks and can help your team:

• Determine which Evaluation Options apply to your specific operations
• Remap your existing compliance documentation to the 2026 numbering
• Build or audit your UM rates data collection and reporting workflows
• Update denial and appeal letter templates for Factor 7 compliance
• Prepare evidence for electronic UM criteria access

For questions about how specific elements apply to your organization, consult the official 2026 Standards and Guidelines and the November 2025 Corrections, Clarifications and Policy Changes document—or reach out to your MHR consultant directly.

Schedule a Discovery Call — [email protected]

© Managed Healthcare Resources, Inc. 2026
Sources: NCQA UM Accreditation 2025 Standards and Guidelines; NCQA UM Accreditation 2026 Standards and Guidelines; NCQA Corrections, Clarifications and Policy Changes to the 2026 UM Accreditation Standards and Guidelines (November 17, 2025); NCQA PCS response to MHR inquiry (December 15, 2025). This blog is for informational purposes and should be read alongside the official NCQA standards publications.