The practices that find PCMH annual reporting painful are almost never the ones that stopped doing the work. They are the ones that did the work all year and then, thirty days before the reporting date, tried to prove it. Someone hunts for the huddle sign-in sheets. The care manager pulls a care plan report and discovers the EHR only keeps 90 days. The quality measure dashboard has changed vendors since last year and the old screenshots don't match. The evidence exists in the practice; it just isn't in a file.
We've helped enough practices through this to have a firm view: the evidence file is built quarterly, not annually, and it is organized by criterion, not by department. This article is how we do it under NCQA's PCMH Standards and Guidelines Version 11.1, which took effect January 1, 2026, and applies to annual reporting for practices whose reporting dates fall this year.
Key takeaways
- The 2026 update raised the medication documentation threshold to 90.1 percent, eased huddle frequency, retired orientation materials, reduced disparity reporting to one driver and added an annual internal performance report.
- Organize the file by criterion, and inside each criterion by documented process, report and de-identified example.
- Run the same report set in the last two weeks of every quarter and save each with the quarter in the file name; this is also how you catch a threshold problem while there is time to fix it.
- The file belongs to the practice on shared storage, not to one person's desktop.
What changed in the 2026 update
NCQA's 2026 update refined several core criteria, retired nine elective criteria that it judged to have become basic expectations of primary care, and added nine new elective criteria centered on virtual care. The changes that most affect what a practice has to document include:
- TC 06: care team huddles are no longer required daily; the minimum is at least twice a week. Your evidence should show the frequency you actually meet, and the policy should match it.
- TC 09: the requirement for written orientation materials was retired. Stop collecting them for PCMH purposes (keep them for HR).
- KM 09: diversity reporting was reduced to one driver of health outcome disparity. Choose the driver deliberately, collect it directly from patients, and report on it consistently.
- KM 14 and KM 15: the medication documentation and reconciliation thresholds rose to 90.1 percent. If your medication reconciliation report was hovering in the high eighties, this is the year it becomes a finding.
- CM 04: person-centered care plans must now be reviewed at least twice a year, so the care plan report needs a "last reviewed" date, not just a "created" date.
- QI 15: a new annual internal performance report covering clinical, cost or coordination, and patient experience measures. Most practices already produce the pieces; the criterion asks for them in one dated document.
If your practice earned recognition under an earlier version, read the current year's Annual Reporting Requirements document from NCQA rather than the one you used last year. The criteria you must report on, and the thresholds, are in that document. NCQA has also published its overview of the updates proposed for 2027, so a practice with a reporting date early next year should read both.
The KM 14 threshold is where we expect most 2026 findings. Say a practice logged 412 transitions of care in the last quarter and reconciled medications for 358 of them. That is 86.9 percent, which passed last year and fails this year. Reaching 90.1 percent on the same volume means 372 reconciliations, only 14 more, which is a workflow fix (a task that fires on every discharge summary) rather than a staffing problem. A practice that runs this report quarterly finds the 14 in March. A practice that runs it the week before the reporting date finds a failed criterion.
Organize by criterion, then by evidence type
Our file structure is one folder per criterion in the annual reporting set, and inside each, three kinds of evidence:
| Evidence type | What it proves | Example |
|---|---|---|
| Documented process | That the practice has a defined way of doing the thing, with a date and an owner | A one-page policy for same-day appointment access, revised and dated in the reporting year |
| Report | That the process runs and at what rate | A medication reconciliation report showing the percentage of transitions with reconciliation, for a recent 3-month period |
| Example | That a real (de-identified) patient experienced it | A care plan screenshot with patient identifiers removed, showing goals, self-management and follow-up |
Not every criterion needs all three, and the annual reporting requirements say which ones need which. But when we cannot tell what a criterion needs, this structure means we already have it.
Name the files so a reviewer, or your successor, can read the folder without opening anything: criterion, evidence type, period, date saved. "KM14_report_2026Q3_2026-09-29.pdf" tells the whole story. A folder of files called "screenshot (3).png" does not, and in our experience that folder is where reporting time goes to die.
The quarterly rhythm
In the last two weeks of every quarter, the PCMH lead runs the same set of reports, saves them with the quarter in the file name, and files them by criterion. The set typically includes access measures (third-next-available appointment, same-day slots used), the care management population report (how patients were identified, how many have care plans and when each was last reviewed), the medication reconciliation rate, the referral tracking report (open referrals, closed loop rate), the clinical quality measure dashboard for the measures the practice has chosen, and the patient experience survey summary. Each report takes minutes to run. Running them quarterly also means the practice sees a problem like an 87 percent medication reconciliation rate in March, with time to fix it, instead of in the annual report.
Huddles, quality improvement meetings and care team meetings get a dated agenda and a two-line note saved to the folder each time. That is the entire meeting-evidence system. Sign-in sheets and photographs of whiteboards are what practices produce when they didn't do this.
The third-quarter run is due now. For a practice with a reporting date in the first quarter of 2027, the reports saved between September 21 and 30 are the most recent full-quarter evidence the submission will carry, so this is the run to do carefully: check that each report shows the practice name, the date range and the measure definition, and that the numbers reconcile with what the quality dashboard shows.
Screenshots that reviewers accept
Reviewers need to see the practice name or logo, the date range, and the data, and they must not see patient identifiers. We crop, we redact, and we annotate in the margin what the screenshot demonstrates. A screenshot of the EHR home screen with a caption saying "care plans are here" is not evidence. A screenshot of a specific de-identified care plan with the goals and follow-up visible, plus the report showing how many patients have one, is.
The mistakes we see
Reports run the week of submission for a period that ended eleven months ago, because the EHR was never set to retain the data. Policies with no revision date, or with a revision date from 2019. Quality measures switched mid-year without a note explaining why, so the trend looks like a failure. And the most common one: evidence assembled by one person who then leaves, so the following year starts from zero. The file has to belong to the practice, on shared storage, with the structure documented.
We also see practices treat annual reporting as separate from the practice's actual quality work. It shouldn't be. The same quality measure report that satisfies a PCMH criterion is the one that drives your gap closure outreach and often your MIPS quality submission. One report, three uses.
Questions we hear
Our reporting date is in November. Is it too late to build the file this way?
Not for this year's core reports, because most can be run for the last three to six months. It is too late for meeting evidence that was never written down, so document what exists honestly and start the rhythm for next year now. Reviewers respond better to a clear account than to reconstructed evidence.
Do we need to re-document criteria that haven't changed since recognition?
Annual reporting asks about a subset of criteria each year, defined in the requirements document, and expects current evidence for those. A policy that has not been reviewed since recognition should at least carry a current review date and signature.
Can someone do this for us?
The Revelrex PCMH annual review works this way: we set up the criterion folders, run the quarterly report cycle with your team, and assemble the submission. The practice still has to do the clinical work; we make sure it can be shown.
What to do this month
- Download the 2026 Annual Reporting Requirements for your reporting date and list the criteria and thresholds that apply to you.
- Create the criterion folders on shared storage and move whatever evidence already exists into them, named by criterion, type, period and date.
- Run the third-quarter report set between September 21 and 30, and check the medication reconciliation rate against 90.1 percent.
- Add a "last reviewed" date to the care plan report and a two-line note template for huddles and meetings.
- Put the fourth-quarter run on the calendar for the second half of December, with a named owner and a named backup.
