CMS Provider Directory Accuracy Requirements: What Plans Get Wrong

Why Provider Directory Accuracy Matters to CMS

The Medicare Advantage provider directory is a member's primary tool for finding in-network care. When it contains inaccurate information — wrong phone numbers, providers who have left the plan, providers listed as accepting new patients who are not — members cannot effectively access their network. CMS has made provider directory accuracy a sustained enforcement priority because directory inaccuracies directly harm beneficiaries, generate complaints, and undermine the integrity of the network adequacy system.

CMS's annual secret shopper studies of MA provider directories consistently find accuracy failure rates exceeding 20% at the provider-data-element level. This is not a fringe compliance issue — it is a pervasive operational problem that most MA plans share, and CMS's enforcement pressure has increased each year.

The Regulatory Requirements

CMS requires that MA organization (MAO) provider directories be:

• Updated within 30 calendar days of receiving provider change information
• Verified for accuracy at least every 90 days through active outreach to providers
• Available in print upon member request within 3 business days
• Available online in a searchable, accessible format
• Accurate for the following data elements: provider name, specialty, address(es), phone number(s), whether accepting new patients, languages spoken, and accessibility features

The 90-day verification requirement is the most operationally demanding. Plans must actively confirm, at least quarterly, that every provider listed in the directory is still contracted, still at the listed address, still reachable at the listed phone number, and still accepting new patients in the status reflected in the directory. For large networks with thousands of providers, this requires a systematic, workflow-driven verification process — not ad hoc updates when the plan happens to become aware of a change.

What Plans Most Commonly Get Wrong

The most frequent provider directory accuracy failures fall into several recurring categories:

Ghost Providers

Ghost providers are providers listed in the directory who are no longer in the network — because they have retired, left the area, terminated their contract, or been excluded from Medicare. Ghost providers are the most damaging accuracy failure because a member who calls the listed phone number may reach someone who has no relationship with the plan, or no one at all. CMS secret shopper studies find ghost providers in a substantial percentage of MA directories tested.

Ghost providers accumulate because plans update directories reactively — when notified of a change — rather than proactively through systematic verification. Providers often leave quietly, without formally notifying the plan, particularly solo practitioners who retire or close their practices.

Address and Phone Errors

Providers with multiple practice locations generate address errors when the directory lists a location that is closed, that the provider has vacated, or that is listed for a different entity than the provider. Multi-location group practices are particularly prone to this error because each practice location may have separate contact information, and one location's data being updated does not automatically update others.

Accepting New Patients Status

A provider listed as "accepting new patients" who is actually not accepting new patients — or is accepting but has a 6-month wait list — creates effective access failures even though the provider is technically in the network. CMS increasingly expects plans to verify accepting-new-patients status as part of the 90-day verification process, not just contract and contact information.

Specialty and Subspecialty Inaccuracies

Plans frequently list providers under specialty categories that do not match the provider's actual clinical focus. A cardiologist listed as "Cardiology" who actually specializes in electrophysiology and does not see general cardiology patients creates a directory that misleads members seeking cardiac care. Subspecialty accuracy requires a more granular understanding of provider practice than most plans routinely collect.

The 90-Day Verification Workflow

Meeting CMS's 90-day verification requirement requires a systematic outreach workflow. High-performing plans implement rolling verification cycles in which every provider in the directory is assigned to a verification cycle cohort, and each cohort is contacted in rotation on a schedule that completes a full directory verification within 90 days. Verification outreach typically includes:

• Phone verification by network operations staff (confirming name, address, phone, specialty, accepting-new-patients status)
• Email verification for providers with known email contacts
• Portal-based self-verification for practices with high digital engagement
• NPPES and PECOS cross-check for enrollment status

Documentation of verification attempts — including date, method, staff member, and response — is essential for demonstrating compliance in a CMS audit. Plans that cannot produce verification logs for each provider in the directory are effectively unable to demonstrate compliance regardless of whether the directory is actually accurate.

Technology and the Accuracy Challenge

Provider directory accuracy is fundamentally a data management problem at scale. Plans with networks of 5,000 or more providers cannot manage 90-day verification cycles with manual, spreadsheet-based workflows without significant labor investment and error rates. Purpose-built provider data management tools that automate verification outreach, track response status, and flag discrepancies for human review are increasingly standard in plans that score well on CMS's accuracy audits.