# QHP Certification TIPS FOR SUBMISSION # SUCCESS Achieving Qualified Health Plan (QHP) Certification is your ticket to participating in the Health Insurance Marketplace® or your State Exchange. To ensure your application is approved, accurate and properly formatted provider data is essential. By following the latest guidelines for Plan Year (PY) 2027, you can position your application for success. Here’s what you need to know about the Network Adequacy Template and Network Adequacy Provider Validations for PY2027. ## Network Adequacy Reminders for Federally-facilitated Exchanges ## Geographic Distance Methodology CMS will measure network adequacy using **geographic** **distance calculations** rather than estimated driving times. This model accounts for topographic factors like rivers, lakes, and mountains which can influence how individuals travel to access care, as well as how health plans organize their networks to meet compliance requirements. ## Alternative Time & Distance Standards ## Alternative Time and Distance (T&D) Standards will be used for certain provider specialty type & county combinations where the Baseline Time & Distance Standards are not feasible due to provider shortages, topographic challenges, or other limitations outside a QHP issuer’s control. In these situations, CMS will use the Alternative T&D Standards to assess an issuer’s network, crediting issuers for in-network providers located beyond the baseline times and distances. ## Guidance for State-based Exchanges We recommend referring to your state guidelines for specific submission requirements and timelines. ## Updates to the Network ## Adequacy Template Changes introduced in PY2026 remain effective for PY2027, including: ## New Data Columns The Network Adequacy Template includes the following two data columns: **•** Provider Grouping **•** Appointment Scheduling Provider Phone Number The **Provider Name field** is split into three fields: **• Provider First Name** **• Provider Last Name** **• Facility Name** ## Three New Specialty Types **• A006 Primary Care** – Advanced Practice Registered Nurse (Adult) **• P006 Primary Care** – Advanced Practice Registered Nurse (Pediatric) **• P201 Dental** – General (Pediatric) Refer to the Network Adequacy Provider Classification and Specialty Framework for more details. --- ## PY2027 Network Adequacy Provider Validations After submitting your Network Adequacy Template, CMS will review your provider data to make sure it’s accurate. If any data errors are identified, you’ll be required to resolve them before resubmitting your application. Below is the list of validations for PY2027. ## PY2027 Network Adequacy (NA) Provider Validations within MPMS **•** Validate that only National Provider Identifiers (NPIs) listed are active and valid in the National Plan and Provider Enumeration System (NPPES). **•** Validate that a P.O. Box is not listed in a provider’s address. **•** Validate that the same NPI is not listed at more than **ten** **unique addresses**. **•** Validate that the same NPI is not selected for both an individual and facility provider. **•** Validate that an NPI does not have multiple Provider Groupings - only one provider grouping should be assigned to a single NPI. **•** Validate that virtual-only or telehealth-only providers are not included. **•** Validate that providers listed on the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) are not included. **•** Validate that the Provider Name fields are completed accurately. **•** Validate that an Advanced Practice Registered Nurse (APRN) is not listed as an individual provider specialty type other than a Primary Care Provider (PCP) or an Outpatient Behavioral Health Provider. **•** Validate that a Physician Assistant (PA) is not listed as an individual provider specialty type other than a Primary Care Provider (PCP). **•** Validate that all required fields of the **Network** **Adequacy Justification Form** have been completed. **•** Validate that providers are correctly classified based on their active practice areas and specialties, as outlined in the NA Provider Classification and Specialty Framework. **•** Validate that only compatible individual provider specialty combinations have been submitted, as outlined in the NA Physician Specialty and Subspecialty Compatibility Matrices. **•** Validate that only the hospitals listed on the NA General Acute Care Hospital (GACH) List are included under the 040 Acute Inpatient Hospital facility specialty type in the NA Template. For additional information on the validations, visit the QHP Certification website. ## PY2027 QHP Data Submission and Certification Timeline Don’t miss a deadline! Download our QHP Application Calendar now to see all key dates for your PY2027 QHP Application. Download Now ## QHP Marketplace Hub Discover more insights, tips, and resources on our QHP Marketplace Resource Hub. Explore the Hub Now ## ® Quest Enterprise Services for QHP Issuers ## QHP Issuers not included. **In a market that’s always evolving, it’s important to** **have a solution that keeps up.** With decades of industry leadership, Quest Enterprise Services®(QES®**) offers your organization a proven approach to adapt and succeed in the Health Insurance Marketplace® and State Exchanges. ## Trusted Network Adequacy Templates At the heart of QES is our industry-renowned network adequacy templates, built with the latest regulatory standards. Our **CCIIO QHP Network Adequacy Template** **and State-Based Exchange Network Adequacy** **Template** equip you with everything needed to evaluate your network against compliance standards effectively. **In addition to the built-in Network Adequacy criteria,** **the CCIIO QHP Network Adequacy Template** includes critical components to support QHP certification and year-round compliance: **•** CCIIO Data Validation Report ## outlined in the NA Provider Classification and **•** CCIIO Data Validations Summary Report **•** CCIIO QHP Submission Report **•** Geographic Distance Calculation Methodology ## in the NA Physician Specialty and Subspecialty Whether you participate in Federally-facilitated Exchanges (FFE), State-Based Exchanges (SBE), or State-Based Exchanges using the Federal Platform (SBE-FPs), QES simplifies year-round compliance while helping you reach your broader business goals. Learn how QES can work for you. Speak with one of our experts today.