“Provider directories are an important tool Medicare Advantage (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.” — Centers for Medicare & Medicaid Services (CMS). 1
Your provider directory is one of the main ways members find and choose in-network doctors, specialists, and facilities for their care. However, inaccurate directory information such as outdated contact details, incorrect network status, or ghost providers can delay receiving care, increase costs, and erode trust in the plan and the broader healthcare system. These same errors can also expose your organization to compliance risk and additional costs.
CMS views inaccurate directories as potentially misleading marketing and continues to strengthen the frameworks behind directory accuracy, recognizing how central provider data is to how your members find care. These frameworks are designed to safeguard access to care and help your directory accurately represent your network.
“It is important that Medicare beneficiaries have the information they need to make the best choice for their health when they are exploring their plan options. Understanding which providers are in a plan’s network is a vital piece for beneficiaries to make an informed choice.” CMS 2
Regulatory oversight of provider directories has evolved from a single set of baseline rules into a more layered structure of overlapping requirements. Staying aligned with these regulations strengthens member satisfaction and builds trust in your network today.
Medicare Advantage Provider Directory Accuracy Regulations
MA organizations are responsible for complying with provider directory accuracy requirements under:
- The Requiring Enhanced and Accurate Lists (REAL) of Health Providers Act
- Medicare Plan Finder
- Existing Requirements
The REAL Health Providers Act Introduces New Provider Directory Accuracy Requirements for Medicare Advantage
Congress passed the “Consolidated Appropriations Act, 2026,” and Section 6220 of that law enacted the Requiring Enhanced and Accurate Lists of Health Providers Act, commonly known as the REAL Health Providers Act. It introduces new provider data accuracy requirements for MA provider directories, aiming to resolve longstanding challenges in maintaining accurate and reliable directories while building upon existing CMS regulations.
What Are the Provider Directory Requirements under The REAL Act?
Beginning with Plan Year 2028, MA organizations must adhere to these updated requirements to ensure compliance. Key changes include more frequent provider data verification, updated timelines for directory changes, and the implementation of both annual accuracy analyses and public accuracy scores.
1. 90-Day Provider Data Verification
MA organizations must verify provider directory information at least every 90 days. This approach aligns with the No Surprises Act, standardizing practices across different health plans by requiring a continuous and proactive process for provider outreach and verification.
- Hospital and Facility Information Validation: The Health and Human Services (HHS) Secretary will determine the required frequency of data validation. While this frequency may differ from the 90-day rule applicable to individual providers, all hospital and facility information must be verified at least once every 12 months.
2. Indicate Unverified Providers in the Directory
Providers whose information has not been verified within 90 days must be clearly labeled in the directory, alerting anyone who reads that information that the provider’s information may not be up to date.
3. 5-Day Removal of Non-Network Providers
Providers no longer participating in a plan’s network must be removed from both online and printed directories within five business days of the determination.
Tip: Remove these providers from all marketing materials to ensure consistency and avoid unnecessary confusion for beneficiaries.
4. Expanded Provider Directory Data Elements
At a minimum, MA organizations must validate, update, and include the following information in their directories:
- Provider Name
- Provider Specialty
- Provider Contact Information
- Primary Office or Facility Address Where Items and Services are Furnished
- Whether the Provider Is Accepting New Patients
- New: Accommodations for People with Disabilities
- Cultural And Linguistic Capabilities
- Telehealth Capabilities
5. Annual Provider Directory Accuracy Analysis and Reports
In addition to ongoing updates, MA organizations must conduct an annual analysis of their directory accuracy and report the findings to CMS. This analysis is based on a random sample of providers listed in the directory, plus an additional random sample from any specialty the HHS Secretary identifies as having a higher-than-average inaccuracy rate, such as mental health or substance use disorder treatment.
MA organizations must then submit the results of this analysis to the Secretary of HHS, along with an accuracy score for the provider directory information, calculated using a verification method specified by the Secretary.
6. Public Provider Data Accuracy Scores
Starting with plan year 2029, MA organizations must display their provider directory accuracy score in their directory.
In addition, the HHS Secretary will publish the accuracy scores in a machine-readable file on a CMS-maintained website, increasing transparency for stakeholders and beneficiaries.
What to Watch Going Forward with Implementing The REAL Act?
CMS and the Office of the National Coordinator for Health Information Technology (ONC) held a public stakeholder meeting on June 15, 2026. They closed the public comment period on June 29, 2026, after receiving feedback on the new Medicare Advantage provider directory accuracy requirements.
They will issue further guidance on how plans are expected to comply, the methodology for accuracy scoring, and additional operational requirements. We encourage you to watch for updates as CMS releases more information. We will also continue to track these developments closely and provide insights and solutions to support your success.
Where the REAL Health Providers Act sets accuracy standards for what’s in your directory, the next set of requirements governs how that same directory data gets submitted to CMS for public display.
Medicare Plan Finder Provider Directory Requirements
CMS expanded provider directory disclosure requirements for MA organizations, which must now 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. The change reduces the need for enrollees to visit multiple websites and supports 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.
What Are the Provider Data Submission and Attestation Requirements for Medicare Plan Finder?
To comply, MA organizations must:
- Submit provider directory data to CMS for inclusion in the Medicare Plan Finder. The data must include:
- The number, mix, and addresses of providers that enrollees can reasonably be expected to obtain services from;
- Each provider’s cultural and linguistic capabilities, including languages offered by the provider or by a skilled medical interpreter at the provider’s office;
- Information on any out-of-network coverage;
- Information on any point-of-service option, including the supplemental premium for that option;
- How the MA organization meets the access requirements under §§ 422.112 and 422.114.
- Submit or make the required data available in the specified format, method, and timeframe set by CMS.
- Update provider directory data within 30 days of becoming aware of any changes.
- Annually attest to the accuracy of provider directory data submitted.
What Are the Implementation Phases for Medicare Plan Finder Integration?
CMS is rolling this out in phases to allow plans time to build toward full compliance.
Current Phase: Phase Two for Contract Year (CY) 2027
MA plans can submit their provider directory data to CMS for use in MPF, using one of two options:
- Machine-Readable JSON Files
- Fast Healthcare Interoperability Resources® (FHIR)-Based JSON Files
Key Dates: CY 2027 Medicare Plan Finder Implementation Timeline
| Date | Milestone |
May 4 – August 31, 2026 | CY 2027 Plan Testing Period |
September 1, 2026 | ❗Attestation Deadline ❗ The CY 2027 attestation must be completed in HPMS. |
Early September 2026 | Plan Preview Window |
September 18, 2026 | Target Deadline for Production-Ready CY 2027 Data |
October 1, 2026 | Production Release of the CY 2027 MPF |
October 15, 2026 | Annual Enrollment Period (AEP) Begins Beneficiaries see the updated directory data on Medicare.gov. |
Reminders
- The JSON file option is temporary. CMS expects all MA plans to migrate fully to FHIR over time, since FHIR is the long-term mechanism for the agency’s planned National Provider Directory.
- Only current, in-network providers and facilities can be included in the directory data supplied to MPF.
- MA organizations must host their data at a publicly accessible URL that CMS can retrieve on a regular basis.
Phase Three: National Provider Directory Using FHIR-Based APIs
CMS is developing a National Provider Directory. Once completed, CMS intends for this directory to draw from MA plans’ own FHIR data and feed it into MPF.
How Do MA Organizations Complete the Provider Directory Attestation?
MA organizations must attest annually, in the Health Plan Management System (HPMS), to the accuracy of the MA provider directory data supplied through this process.
Important Note
The attestation must be completed electronically by an authorized official of the organization: the Chief Executive Officer (CEO), Chief Financial Officer (CFO), and/or Chief Operating Officer (COO). That individual is personally attesting that the provider directory information is “accurate, complete, and truthful at the time of the attestation to the best information, knowledge, and belief of the MA organization.”
Reminders
- Route the data to that signature several days before the deadline, leaving room to resolve any issues.
- The CY 2027 attestation must be completed in HPMS no later than September 1, 2026.
Will CMS Suppress Provider Directory Data on Medicare Plan Finder?
Yes, CMS reserves the right to suppress a plan’s provider directory data from MPF when:
- The MA organization fails to complete the provider directory attestation
- The validation process results in fatal errors for a submitted file
- Reported data-quality issues exceed a threshold CMS has published
Where Can MA Organizations Find Technical Guidance About Medicare Plan Finder?
CMS publishes ongoing technical guidance and memos to help MA organizations navigate the finer points of Medicare Plan Finder implementation. The resources below cover the current testing cycle and technical specifications you can reference while preparing your CY 2027 submission.
- Testing Information for the MA Provider Directory Data for Use in Medicare Plan Finder Initiative Download Memo
- CY 2026 Technical Implementation Guide for the MPF MA Provider Directory Download Memo
See where your provider data stands against the REAL Act, Medicare Plan Finder, and existing CMS requirements. Get the toolkit to understand your process and see if you’re on target.
Free Provider Data Accuracy Audit Toolkit for Medicare Advantage Organizations
Existing Medicare Advantage Provider Directory Requirements
Separate from the REAL Health Providers Act and the Medicare Plan Finder submission requirements above, MA organizations already have provider directory obligations under existing regulations. These require MA plans 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.
1. Online and Printed Directories
Provider directories (online and printed) must meet the following timelines:
- Annual deadline: Available to current enrollees by October 15th of the year before the applicable plan year.
- New enrollees: Provided within 10 calendar days of CMS confirming enrollment, or by the last day of the month before the coverage effective date, whichever is later.
- Upon request: Provided to current enrollees within three business days of any 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
MA organizations must confirm the accuracy of their directory information every quarter. Data elements to verify and update, at a minimum, the following directory information:
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 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.
Updates: Must be revised whenever the MA organization becomes aware of a change.
- Online directories: updated within 30 days of receiving the new information.
- Printed directories: updated within 30 days as well, though a printed directory is considered current if paired with a separate addendum reflecting the changes.
Tip: 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 Can Medicare Advantage Organizations Not Do?
To ensure members are not misled, CMS prohibits MA organizations from certain practices in their directories:
- Listing providers before they are fully credentialed by the plan.
- Listing 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).
Listing 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 Does CMS Monitor Medicare Advantage Provider Directory Compliance?
Compliance monitoring remains a core function of CMS’s oversight framework. CMS assesses the accuracy of your provider directories through directory audits, data validation checks, and secret shopper surveys, and reinforces these efforts through its Triennial Network Adequacy Reviews. X
MA organizations are also required under federal law to monitor and maintain network adequacy and provider directory accuracy throughout the year and 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.
Maintain audit-ready documentation to track which providers have validated their information and which have not. This approach supports compliance and simplifies reporting efforts.
Medicare Advantage Provider Directory FAQs
Who is responsible for keeping the provider directory accurate?
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 Organizations find provider directory guidance?
Provider types required for inclusion in directories are outlined annually in the Medicare Advantage and Section 1876 Cost Plan Provider Directory Model and Instructions.
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, or is covering for another provider, that address should not be included in the directory. Instead, provide the location where the provider is available on a consistent basis.
What are the rules about provider specialties?
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.
Quest Enterprise Services® for Medicare Advantage Organizations
As these regulations evolve, the administrative and operational requirements MA organizations must meet keep expanding as well. Quest Enterprise Services® (QES®) for Medicare Advantage is here to help you meet the REAL Act, Medicare Plan Finder, and existing CMS requirements covered here with QES® Accuracy, our solution to enhance your process, improve data transparency, reduce ghost networks, and strengthen compliance. Have questions? Reach out to us today and let our experts guide you.
Related Resources on Medicare Advantage Requirements
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