Provider directory accuracy is essential for improving access to healthcare services for Medicare Advantage (MA) beneficiaries. According to the Centers for Medicare & Medicaid Services (CMS), “Provider directories are an important tool MA enrollees use to select and contact their physicians and other contracted providers who deliver medical care. Beneficiaries and their caregivers rely on provider directories to make informed decisions regarding their health care choices. Inaccurate provider directories can create a barrier to care and raise questions regarding the adequacy and validity of the MAO’s network as a whole.”
Given the pivotal role provider directories play, CMS continues to prioritize frameworks to improve their accuracy. Common errors, such as outdated contact information, ghost providers, incorrect network status, and inaccurate practice locations, create significant challenges for those seeking healthcare services. These inaccuracies can lead to member frustration, delays in care, and diminished trust in the healthcare system.
CMS also considers inaccuracies in provider directories as potential instances of misleading marketing.
To address these concerns, CMS has established provider directory requirements for MA organizations. Your organization can benefit greatly from understanding these regulations and keeping processes aligned with compliance requirements.
CY2026 Final Rule: New Provider Directory Requirements
CMS expanded provider directory and disclosure requirements for MA organizations through the Medicare and Medicaid Programs Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program Final Rule. Under this amendment, MA organizations must submit provider directory data directly to CMS for integration into the Medicare Plan Finder (MPF) website—a centralized platform that helps Medicare beneficiaries compare and select health plans during the annual open enrollment period.
By requiring the direct submission of provider directory data, CMS aims to simplify the consumer experience of comparing provider networks across different plans by reducing the need for them to visit multiple websites and ultimately support more informed healthcare decisions. Additionally, the change aligns with CMS’s broader initiatives for Patient-Centric Healthcare Ecosystem, which seeks to improve access to healthcare provider information for Medicare beneficiaries and create a National Provider Directory.
The New Medicare Advantage Provider Directory Requirements You Need to Know
As part of the updated requirements, MA organizations are required to submit data to CMS/HHS for online publication in the Medicare Plan Finder, submit or make the required data available in the specified format, method, and timeframe set by CMS, update the data within 30 days of becoming aware of any changes, and annually confirm that all submitted or available information is accurate, following CMS requirements.
CMS plans to release further operational guidance, including technical specifications, to support compliance with these requirements.
Special Election Period for Incorrect Medicare Plan Finder Information
CMS also created a temporary Special Election Period (SEP) for Incorrect Medicare Plan Finder MA Provider Directory Information, designed to address potential errors during the rollout of the updated Medicare Plan Finder provider directory data. This temporary SEP is intended to protect beneficiaries who may encounter inaccurate provider information during the first year of implementation.
“CMS expects that the provider directory information in Plan Finder will be accurate. However, despite our best efforts, individuals might still see incorrect information on the MPF provider directory, especially in the first year of implementation. To support individuals during the first year of the MPF provider directory, a Special Election Period (SEP) will be available to ensure that individuals are able to leave their current plan if they relied on inaccurate information while enrolling through MPF,” CMS stated.
The SEP applies to MA enrollees who relied on the MPF provider directory information, enrolled in a MA plan through MPF, and discovered, within 3 months, that their preferred provider was not actually in the chosen MA plan’s provider network. “The intent of this SEP is to allow an individual to make a change to their MA plan election in order to stay with their preferred provider,” explained CMS.
For more details regarding this SEP, refer to CMS’s memo dated September 12, 2025, titled “Special Election Period for Incorrect Medicare Plan Finder Medicare Advantage (MA) Provider Directory Information.”
Existing Medicare Advantage Provider Directory Requirements
Under existing regulations, MA organizations have additional provider directory requirements. MA organizations are required to make information about their provider networks accessible both online and in printed form, and ensure that the required information about providers is provided in a clear, accurate, and standardized form. Below are the essential requirements.
1. Online and Printed Directories
Online and printed directories must be available by October 15th annually, within 10 days of a new member’s enrollment, and provided to current enrollees upon request, within three business days of the request.
2. Searchable Provider Directories
Online directories must be searchable by every data element required in the model provider directory. This includes information such as name, location, specialty, and the provider’s cultural and linguistic capabilities.
3. Provider Verification
Provider Directory Data Elements
- Provider Name
- Provider Specialty
- Whether or Not the Provider Accepts New Patients
- Practice Address
- Phone Number
- Provider Offers Telehealth Services
- Provider’s Cultural and Linguistic Capabilities, Including Languages and American Sign Language
💡 CMS highlights the importance of having an established system in place to proactively ensure data integrity rather than relying solely on providers to notify them of changes.
CMS also encourages plans to incorporate the following information about providers into the provider directory, as practicable:
- Provider’s website and e-mail address
- Provider’s ability to support electronic prescribing
- Provider’s medical group and/or institutional affiliation
- Provider’s telehealth capabilities
- Provider’s expertise in treating patients with opioid use disorder (OUD) (e.g., prescribers of medications for OUD, addiction specialists, Opioid Treatment Programs (OTPs))
4. Update Directory Information in 30 Days
Provider directory data must be updated within 30 days of any changes reported by providers or identified by the plan. Whether a provider departs, joins, or updates their contact information, health plans must reflect changes within their directory submissions to CMS. Plans must also update hardcopy provider directories within 30 days, but hard copy directories that include separate updates via addenda are considered up-to-date.
💡CMS suggests that MA organizations consider including clauses in their provider contracts that mandate the provider to communicate updates. CMS views these contracts as a valuable means for MA organizations to fulfill their obligation to maintain accurate provider directories.
5. What Medicare Advantage Plans Cannot Do
To ensure members are not misled, CMS prohibits health plans from certain practices in their directories:
- Listing providers before they are fully credentialed by the plan.
- List a provider if the enrollee cannot call the phone number listed and request an appointment with that provider at the address listed (e.g., urgent care or residential facilities; locations where the provider only has admitting privileges, only treats inpatients, or exclusively reads tests at the location).
List locations where a provider may practice only occasionally (e.g., locations where the provider is covering for other providers or locations within the practice where the provider does not regularly see patients).
How CMS Monitors Compliance
Compliance monitoring remains a core function of CMS’s oversight framework. Activities like directory audits, data validation checks, and secret shopper surveys are used to assess the accuracy of the health plan’s provider directories. CMS’s Triennial Network Adequacy Reviews further reinforce the oversight activities as well as the need for MA organizations to have a process for consistent compliance.
CMS reminds MA organizations that they are required under federal law to monitor and maintain network adequacy and provider directory accuracy throughout the year. Additionally, MA organizations should promptly inform their CMS Account Manager of any non-compliance issues or significant changes in their provider network.
Non-compliance can lead to consequences, such as corrective action plans, financial penalties, contract denial, or other enforcement measures.
💡 Tip: To avoid enforcement actions, have a process that allows you to easily document and understand which providers have validated their information and which providers have not.
FAQs
Who is Responsible for Directory Errors?
MA organizations are responsible for provider directory accuracy. CMS acknowledges the complexities surrounding directory errors but emphasizes that MA organizations must comply with existing regulatory requirements. Additionally CMS, “strongly encourages MA organizations to institute procedures that support the ongoing accuracy of their provider directory. Therefore, the MA organization retains responsibility for data accuracy through the implementation of best practices.”
Where can MA plans find guidance on required provider types for inclusion in directories?
Provider types required for inclusion in directories are outlined annually in the Medicare Advantage and Section 1876 Cost Plan Provider Directory Model and Instructions. For example, instructions for the 2026 requirements will be available in the respective yearly guidance document provided by CMS.
Which providers should be listed in the directory?
Listings should be limited to currently contracted and fully credentialed providers.
What are the rules about listing practice locations for providers?
You can list only the locations where a provider regularly practices and is regularly available to provide covered services.
Example: If a provider occasionally sees patients at a satellite location once a month, that address should not be included in the directory. Instead, provide the location where the provider is available on a consistent basis.
How do I ensure provider specialties are accurately represented?
Providers must be listed with the capacity in which they are serving for that particular network (i.e., specialty and/or sub-specialty), even if the provider is credentialed in more than one specialty.
Example: An internal medicine physician/oncologist who does not practice as a PCP should not be displayed as a PCP in the directory.
List the provider only under the category of the services they will be furnishing to enrollees as an in-network provider.
Building Strong Systems for Provider Directory Maintenance
Compliance with CMS’s provider directory requirements is an ongoing process that demands diligence, collaboration, and systemized approaches. Accurate directories do more than avoid penalties—they help your members access timely care, foster confidence in your network, and reflect positively on your health plan.
By using the right tools to enhance data visibility, improve your validation processes, and strengthen provider collaboration, your organization can exceed CMS standards while putting members first. When beneficiaries trust your directories, they trust your plan—and that trust drives growth, retention, and member satisfaction. Adhering to CMS standards is not only about compliance but also about building a network your members can rely on effortlessly.
Access our extensive CMS Medicare Advantage and Medicaid Resource Hub for the latest insights on network adequacy and provider directory accuracy regulations and compliance requirements.
Quest Enterprise Services® for Medicare Advantage Organizations
As these regulations evolve, MA organizations want to stay informed and adapt strategies to meet new administrative and operational requirements. Quest Enterprise Services® (QES®) for Medicare Advantage is here to assist you throughout this process, offering an enterprise solution, expert guidance, and actionable insights to help you optimize your provider networks and ensure compliance. Have questions? Reach out to us today and let our experts guide you.
Related Resources on Medicare Advantage Requirements
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