Quest Analytics

Healthcare Payer Executives Reveal How Network Strategy and Design Drive Organizational Success

Quest Analytics — Thu, 12 Mar 2026 21:37:26 +0000

How are health insurance executives adapting their provider network strategies in a world where technology is rewriting the rules? Optimizing provider networks starts with provider network design. For years, the healthcare industry has voiced concerns about unreliable and siloed data, hindering the efficiency of building, managing, and optimizing provider networks. Now, as digital transformation continues to accelerate, technologies such as advanced analytics, machine learning, and automation are reshaping decision-making processes across the industry and providing payers the chance to address long-standing challenges. While these innovations hold promise, operationalizing smarter, value-driven networks remains elusive. Many health plans still face barriers like poor data quality, limited analytical capabilities, and execution challenges.

To better understand how health plan leaders are navigating this transformation, we partnered with Becker’s Healthcare to survey executives who are leading these efforts.

The participants included 100 Directors, Vice Presidents, and C-suite leaders across national and regional health plans in Commercial, Marketplace, and Medicare Advantage sectors. Participants were responsible for provider network management, network performance, network adequacy, provider data accuracy compliance, network builds, and new market expansion. What they shared shed light on the priorities, obstacles, and opportunities influencing how executives engage with provider data and analytics to design, evaluate, and optimize their provider networks.

Live Insights from Becker’s 3rd Annual Payer Issues Roundtable

At Becker’s 3rd Annual Payer Issues Roundtable, Bob Tavernier, Sales Solutions Executive at Quest Analytics®, and Karen Tachian, Senior Director of Network Regulatory Operations at Health Care Service Corporation, explored insights derived from the study. Their discussion addressed how health plans can bridge the provider data quality gap, meet increasing regulatory requirements, and ensure meaningful member outcomes while keeping network design at the forefront of their strategies.

Top Priorities for Executives Shaping Provider Network Strategies

When asked about their top objectives for the next five years, participants identified four foundational initiatives.

1. Improve Member Satisfaction

2. Improve Clinical Quality

3. Drive Membership Growth in Existing Markets

4. Lower Administrative Costs

These priorities provide a framework for guiding resource allocation, influencing investment decisions, and driving strategic planning. While these goals establish a path forward, executing them requires a closer examination of the role provider network design plays in achieving them.

The Role of Provider Network Design in Driving Success

Participants evaluated the influence of provider network design on their organizational goals, reaching a strong consensus: network design has a direct impact on achieving these goals. Survey responses highlighted its importance in various top initiatives.

Improve Member Satisfaction: 65% of respondents said Network Design is “Essential” or “Very Important” to improve member satisfaction.

Expand into New Markets or Lines of Business: 65% of respondents rated Network Design as “Essential” or “Very Important” to expand into new markets or lines of business

Improve Clinical Quality: 37% of respondents ranked Network Design as “Essential” or “Very Important” to improve clinical quality.

Lower Administrative Costs: 53% of respondents ranked Network Design “Very Important” to reduce administrative costs.

Beyond these priorities, participants also attributed network design as a driver of other strategic goals, including Improve Medicare Advantage Star Ratings, Drive Membership Growth in Existing Markets, Lower Medical Expenses & Healthcare Costs, and Maintain Compliance & Avoid Regulatory Penalties.

These findings illustrate a widespread recognition that the architecture of a provider network can influence everything from care access to profitability. Tavernier elaborated on this point, stating, “In many ways, your provider network determines your outcomes, whether it’s care quality, member loyalty, or compliance. If the network isn’t designed well, achieving those outcomes becomes more difficult.”

Participants acknowledged the importance of having a proactive rather than reactive approach to provider network design, evaluation, and optimization. However, this shift requires addressing systemic challenges—none more significant than the effective use of data.

The Key Challenges in Provider Network Optimization

Interestingly, when participants were asked to identify the data insights they consider critical for evaluating and optimizing provider networks — and whether they actively use those same data insights in their network analysis — the results revealed a gap between the value leaders attribute to specific data and their practical application of it. Several data insights were acknowledged as important but used less frequently than anticipated.

Competitor Network Composition: While 71% responded that this data is “Essential” or “Very Important,” only 40% actively use it when evaluating their networks.

Provider Cost and Utilization Efficiency: 65% said these insights are “Essential” or “Very Important,” yet only 23% reported using these insights in their network evaluations.

Member Access to Care: 53% viewed these insights as Very Important, and 53% incorporate them into their evaluations today.

Negotiated Rates for Competitors: 37% responded that this data is “Essential” or “Very Important,” yet 18% of respondents reported using this data in their network analysis.

Value-Based Care Readiness: 37% responded that this data is “Essential” or “Very Important,” yet 18% of respondents reported using this data in their network analysis.

What’s Driving the Data Gap?

This paradox raises the question: Why are these data insights not used, even though they are widely recognized as critical for network evaluation and optimization? Feedback from participants pointed to data quality as a key barrier to leveraging these insights. Many reported low confidence in the reliability of existing datasets. For example:

Provider Cost and Utilization Data: 42% of respondents rated the quality of this data as Poor.

Member Access-to-Care Data: 53% of respondents indicated that current datasets were of only Moderate quality.

Competitive Data: 0% of respondents considered their competitive data to be of High Quality.

The root causes of these issues lie in outdated verification processes and fragmented data infrastructures. Participants cited flaws in traditional approaches to provider data collection—such as manual provider verification or reliance on unvalidated web-sourced data. These methods allow inaccuracies to persist and remain a recurring concern tied directly to poor data management.

Tavernier explained the ripple effects of unreliable data across the healthcare ecosystem, stating, “When data isn’t dependable, it hinders every phase of the network lifecycle. Designing and optimizing networks becomes slower, more error-prone, and far less strategic. Without reliable data, organizations are essentially flying blind when it comes to building high-quality networks and delivering care pathways that drive better outcomes.”

Evolving Regulatory Requirements Amplify Data Accuracy Needs

Diving deeper into provider data integrity, the study highlighted how expanding regulatory requirements for provider directory accuracy are adding new layers of complexity to network design and optimization. One area of vulnerability for many health plans is the presence of ghost providers—individuals or entities listed in directories who are no longer active participants in a network.

Regulators are placing increasing emphasis on addressing ghost providers listed in directories and other plan marketing materials, particularly in the lead-up to Open Enrollment. To protect consumers and ensure that directory listings reflect active, practicing providers, some regulators are introducing additional data validation reporting requirements. These evolving requirements are designed to improve transparency and support informed decision-making for healthcare consumers shopping for healthcare options.

Interestingly, while survey participants expressed confidence in their capabilities to manage ghost providers, independent research conducted by Quest Analytics revealed a contrasting perspective. Findings show that more than two-thirds of networks studied exhibited ghost provider rates exceeding 9%, suggesting a potential blind spot for many health plans.

To resolve this challenge, solutions like Quest Enterprise Services® (QES®) Accuracy offer proactive provider attestation and targeted, actionable insights to help health plans identify and remove ghost providers. By prioritizing data integrity, plans can create directories that are both compliant and trusted by members.

Balancing Network Compliance with Marketability in Network Design

Participants emphasized that provider network design has evolved into a critical differentiator, requiring a careful balance between meeting regulatory network adequacy standards and creating member-centric, marketable networks. While regulatory compliance is essential, executives are increasingly recognizing the need to incorporate advanced data insights to offer networks that go beyond network adequacy and deliver competitive value.

One regional health plan executive shared, “At first, our focus was solely on meeting network adequacy requirements. However, we soon realized that compliance alone wasn’t enough to differentiate us in the market. To truly stand out, we needed a more comprehensive approach, one that integrated reliable data insights into our network analyses.”

Tavernier reinforced this perspective, stating, “Compliance keeps you in the game, but to compete and thrive, you need to exceed the baseline.” He acknowledged the challenges of achieving this balance while underscoring the importance of taking a holistic approach to data. According to Tavernier, integrating reliable data insights, such as provider utilization, provider quality metrics, and competitor analysis, is critical for achieving both compliance and differentiation. By leveraging these insights, health plans can create and refine networks that not only meet regulatory standards but also improve member experience, build loyalty, and drive long-term growth.

Building An Actionable Vision for Network Improvement

During the discussion on priorities and actionable steps, participants emphasized the significance of developing strategic roadmaps to guide progress. They suggested designing roadmaps that balance short-term goals, such as annual milestones and specific projects, with broader long-term objectives, typically spanning three to five years. By taking a flexible, adaptive approach, they found their data systems, workflows, and evaluation processes evolved cohesively, contributing more effectively to lasting success.

Tavernier highlighted the need for health plans to treat their networks as dynamic systems, explaining, “A provider network is never static, and neither are your members. Both are constantly evolving, and staying effective requires the ability to understand and adapt to those changes in real time. By focusing on practical, incremental steps, you can achieve meaningful progress that builds over time.” He reiterated this strategy, stating, “While you can’t solve every challenge at once, a structured, data-driven approach allows you to steadily enhance outcomes for your members and your organization.”

Looking Toward the Future of Provider Networks

Designing and optimizing networks is fast becoming a top priority in the shift toward member-centric care. The opportunities created by better data, advanced technology, and redefined strategies are setting the stage for a more connected and efficient industry.

Overcoming persistent barriers, such as data quality, system integration, and regulatory expectations, requires sustained effort alongside innovation. Yet for health plans that commit to addressing these challenges, the rewards are evident. Member satisfaction, cost efficiency, care quality, and regulatory alignment are all within reach for those willing to adapt their approach.

Tavernier’s final insight captures the promise of this transformation: “The future belongs to health plans that can connect all the dots: better data, smarter strategies, and more member-focused networks. When those elements work in harmony, the outcomes can be transformative.”

For any plan seeking growth and innovation, the path forward lies in infusing every level of provider network design with purpose and insight. By doing so, organizations will deliver both meaningful care and achieve lasting success in an ever-evolving healthcare landscape.

Related Network Performance Resources

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Know Your Data, Grow Your Business

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Ghost Networks in Healthcare: What They Are and How To Address Them

Quest Analytics — Tue, 24 Feb 2026 16:00:42 +0000

Ghost networks have increasingly become a central topic in discussions within the healthcare sector and legislative circles. As this issue gains attention, it is crucial to understand the implications of ghost networks and explore strategic solutions. By examining the complexities of ghost networks, identifying their causes, and outlining the necessary steps to mitigate their impact on patient care and healthcare administration, we can better address this growing concern.

What is a Ghost Network?

A ghost network refers to healthcare providers listed in a health plan’s provider directory who are not actually available to provide care as indicated. These inaccuracies can occur when the directory lists incorrect information about the provider, such as the wrong specialty, practice location, or contact details. Ghost networks also occur when a health plan’s directory lists providers who are not accepting new patients or are not contracted with the network, misleading consumers into thinking they can access care that is truly unavailable.

Ghost networks occur when health plan directories contain inaccurate or outdated provider listings.

Inaccurate provider specialty type, practice location, or contact details
Providers who are not accepting new patients
Providers who are not part of the plan’s network

What Causes a Ghost Network?

Similar to provider data accuracy, several factors contribute to creating ghost networks. Here are the most common reasons.

1. Provider Data Accuracy Challenges

Maintaining provider data accuracy is a multifaceted challenge. Network data frequently changes as providers update their panel status, retire, or change their contact information. This dynamic nature, coupled with communication gaps about regular provider data updates and verification often results in provider directories containing outdated information.

To learn actionable tips for enhancing provider data accuracy, improving outreach, and achieving better outcomes, read 5 Best Practices: Improving Provider Data Accuracy, Provider Outreach and Outcomes

2. Varied Provider Directory Requirements

Each market or plan product has its own set of provider directory accuracy requirements. Provider directory policies and procedures, specific reporting on provider outreach metrics, distinct data verification elements, and varying timeframes, complicate efforts to maintain consistent and up-to-date data across the organization. This fragmentation can lead to directories with outdated or incorrect information.

3. Difficulty Integrating Data Updates

Healthcare organizations often rely on multiple data systems, each serving different purposes and used by different teams. Synchronizing provider data across these systems can be challenging, and delays in updates or issues with version control can increase the likelihood of errors. For instance, consider information on providers who have changed locations. If updates or changes are not integrated effectively, ghost providers can accidentally be left in the data and the provider directory.

4. Employee Turnover and Shifting Initiatives

When employees transition to new positions or teams take on new responsibilities, knowledge gaps and inconsistencies can arise. These shifts can result in delays or omissions in critical updates. For instance, if an employee formerly responsible for updating provider data moves to a new role and does not properly transfer their duties, essential updates may be missed.

What are the Implications of Ghost Networks?

Ghost networks can profoundly disrupt the healthcare ecosystem. Results showed that more than two-thirds of networks included in an independent study presented ghost provider rates over 9%. Their inclusion in provider directories and network analyses can degrade service quality and financial performance. Core implications encompass inefficiencies in resource allocation, elevated administrative costs, lost market opportunities, heightened member dissatisfaction and churn, and exposure to regulatory and legal penalties.

To learn more about the costs of ghost networks, read our article, How Ghost Networks Impact Health Plans and Health Systems.

Regulatory Attention on Ghost Networks

Recognizing the potential harm from misleading information in provider directories, lawmakers are now focusing on reducing ghost networks. To address these concerns, regulators are considering the use of claims data to identify whether providers are actively treating patients or if they are ghost providers.

For instance, the Centers for Medicare & Medicaid Services (CMS) has implemented new requirements for Medicare Advantage Organizations. These regulations require organizations to verify and provide documentation showing that certain Outpatient Behavioral Health specialties have treated at least 20 patients in the past year. The verification process utilizes reliable data sources, such as claims data, prescription drug claims, and electronic health records, to ensure the accuracy and reliability of provider information.

New Federal Legislation

Requiring Enhanced & Accurate Lists of Health Providers Act

Update! The Requiring Enhanced & Accurate Lists of Health Providers Act, or the “REAL Health Providers Act has been signed. This new legislation is designed to address the issue of “ghost networks” by enforcing stricter requirements for Medicare Advantage provider directory accuracy. To find out more about these changes, read our article: The REAL Health Providers Act Signed Into Law: New Provider Directory Accuracy Requirements for Medicare Advantage.

Proposed Federal Legislation

Behavioral Health Network and Directory Improvement Act

Another proposed federal bill, the Behavioral Health Network and Directory Improvement Act, aims to address the issue of ghost networks in behavioral health care for individuals enrolled in private health insurance plans. The act proposes stricter requirements for provider directory accuracy, including mandatory independent audits of health plan networks by both the federal government and the health plans themselves. Audit results would be published online for public transparency, with civil monetary penalties for non-compliance. Additionally, the bill calls for higher network adequacy standards, parity standards to keep behavioral health reimbursements on par with physical health, and for behavioral health providers to regularly update the information they submit to health plans, including timely information on whether they can accept new patients.

States Fighting Ghost Networks with Requirements

Several states, including Illinois, Oklahoma, New Mexico, and Massachusetts, have implemented measures to reduce ghost providers. These measures include incorporating claims data as a signal of provider activity.

Three Strategies to Minimize Ghost Networks in Healthcare Organizations

To mitigate the prevalence of healthcare ghost networks and ghost providers, healthcare organizations can adopt the following strategies.

Invest in an Enterprise Provider Network Management Solution

Selecting a comprehensive provider network management solution is your first step to minimizing ghost providers. Look for a platform that offers continuous data analysis and insights. This platform should be able to identify which providers are actively seeing patients and at which locations, pinpoint data discrepancies, and provide actionable insights for resolution.

Enhance Provider Verification to Improve Provider Data Accuracy

Partnering with a trusted organization like Quest Analytics® can greatly enhance provider data accuracy. Quest Enterprise Services® Accuracy includes provider verification support through outreach services and regular data updates. Our continuous 90-day outreach process provides consistent attestations, providing you with the information necessary to ensure your directory lists providers who are actively participating in the network.

Prioritize Solutions that Promote Seamless Cooperation between Teams

Effective provider network management relies on strong collaboration and the participation of multiple teams within your healthcare organization. Prioritize solutions that promote seamless cooperation between teams, enabling flexibility in network viewing and the sharing of key insights.

By implementing these strategies, you can strengthen your provider networks, minimize the occurrence of ghost providers, and improve provider directory accuracy.

Ghost networks and providers are a significant problem in the healthcare industry. Fortunately, health plans and providers can take steps to identify and eliminate these ghost providers through the use of advanced analytics solutions. By ensuring the accuracy and completeness of healthcare provider data, we can eliminate ghost networks, resulting in higher quality of care, more significant cost savings, and improved patient outcomes.

Ghost Network Prevention with Quest Analytics

Identify ghost providers and optimize the value of your network by ensuring it’s adequate, accurate, and active with Quest Enterprise Services® Accuracy and Quest Enterprise Services® Provider Claims Insights.

Proven Solutions for Your Provider Network Management

Looking to simplify your workload? Let Quest Analytics take on the heavy lifting! Our solutions and dedicated team specialize in provider data accuracy and provider network adequacy for various lines of businesses, including Medicare Advantage, Medicaid and Commercial. Schedule a strategy session today and see how we can help you every step of the way.

Start a Conversation Today!

The REAL Health Providers Act Signed Into Law: New Provider Directory Accuracy Requirements for Medicare Advantage

Quest Analytics — Tue, 24 Feb 2026 10:05:28 +0000

Update: On February 3, 2026, H.R. 7148, the “Consolidated Appropriations Act, 2026,” was signed into law. This legislation enacted the Requiring Enhanced and Accurate Lists of Health Providers Act (REAL Health Providers Act), which introduces new requirements for Medicare Advantage (MA) provider directory accuracy. These provisions address persistent challenges in keeping directories up to date and build upon existing MA provider directory accuracy requirements.

Beginning with plan year 2028, MA organizations must comply with updated regulations. 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.

New Medicare Advantage Provider Directory Accuracy Requirements

1. Verify Provider Data Every 90 Days

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.

For hospitals or other facilities identified as appropriate by the Health and Human Services (HHS) Secretary, verification may occur less frequently but must be conducted at least once every 12 months.

2. Indicate Unverified Providers in the Directory

If a provider’s information isn’t verified within 90 days, MA organizations must clearly indicate in the directory that the provider’s information may not be up to date.

3. Remove Non-Network Providers Within 5 Days

When it is determined that a provider is no longer participating in the network of such plan, MA organizations must remove that provider from the online and printed directory listings within five business days.

4. Expanded Provider Directory Information Criteria

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
Accommodations for People with Disabilities
Cultural And Linguistic Capabilities
Telehealth Capabilities

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.

1. Conduct Directory Accuracy Analysis

Analyze the provider directory information for accuracy using a random sample of providers listed in the directory.
The random sample shall include a random sample of each specialty of providers with a high inaccuracy rate of provider directory information relative to other specialties of providers, as determined by the Secretary of Health and Human Services (HHS). Examples cited of such specialties are mental health or substance use disorder treatment.

2. Submit a Report to HHS

Provide a report to the Secretary of HHS that includes:

The results of the directory accuracy analysis, along with the accuracy score for the provider directory information.
This score will be based on a verification method specified by the Secretary.

Public Display of Provider Directory Accuracy Scores

Starting with plan year 2029, MA plans must display their provider directory accuracy score prominently on their provider directories.

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.

Upcoming CMS Guidance Updates

CMS will issue further guidance to clarify how plans will be expected to comply, methodologies for accuracy scoring, and additional operational requirements. We encourage you to stay informed by watching for updates as CMS provides more information. Additionally, we will continue to track these developments closely and provide insights and solutions to support your success.

Time to Prepare: How Quest Analytics Can Help MA Plans

With compliance deadlines just over the horizon, reliable solutions and processes are pivotal. Quest Enterprise Services® (QES®) Accuracy is the trusted solution that helps MA organizations address challenges related to provider network adequacy and directory accuracy.

How QES Accuracy Positions You for Success:

Streamlined Provider Outreach: Automate and improve data collection workflows.

Proactive Risk Management: Eliminate bottlenecks and inaccuracies, reducing the potential for penalties.

Analytics-Driven Insights: Apply dynamic analytics to improve data management and achieve higher directory accuracy scores.

Full-Service Support: From a dedicated Client Services team to compliance solutions, we help your organization thrive amidst regulatory change.

The new requirements are a turning point for provider directory accuracy regulations, driving transparency and reliability for stakeholders across the healthcare ecosystem. By starting preparation now, MA organizations can minimize disruption, meet new compliance standards confidently, and position themselves as leaders in the industry.

Proven Solutions for Your Provider Network Management

Looking to simplify your workload? Let Quest Analytics® take on the heavy lifting! Our solutions and dedicated team specialize in provider data accuracy and provider network adequacy for various lines of businesses, including Medicare Advantage, Medicaid and Commercial. Schedule a strategy session today and see how we can help you every step of the way.

Start a Conversation Today!

The Latest Medicare Advantage Provider Directory Requirements

Quest Analytics — Thu, 12 Feb 2026 09:23:30 +0000

“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,” the Centers for Medicare & Medicaid Services (CMS).

Provider directories serve as a critical resource for MA beneficiaries, helping them navigate their healthcare options and connect with physicians and providers. However, inaccuracies in directory data—such as outdated contact information, incorrect network status, or ghost providers—undermine this process. These errors can frustrate members, delay care, and erode trust in the healthcare system. Recognizing the impact of inaccurate directories, CMS views such deficiencies as potentially misleading marketing and has made enhancing directory accuracy a priority.

Given the essential role provider data and provider directories play in facilitating care for MA health consumers, CMS continues to implement frameworks that improve their reliability. Through these efforts, the agency seeks to reduce barriers to care and ensure directories accurately reflect the composition and accessibility of MA networks. For MA organizations, understanding and complying with these requirements is essential—not only to maintain compliance but also to deliver high-quality experiences for beneficiaries.

By aligning your processes with CMS regulations, your organization can strengthen member satisfaction, minimize inaccuracies, and contribute to a healthcare ecosystem that fosters trust and transparency.

New: The REAL Health Providers Act Introduces New Provider Directory Accuracy Requirements for Medicare Advantage

The provider directory landscape is about to undergo significant updates following the passing of the “Consolidated Appropriations Act, 2026.” This legislation included the Requiring Enhanced and Accurate Lists of Health Providers Act (REAL Health Providers Act), introducing new provider data accuracy requirements for MA provider directories. These provisions aim to resolve longstanding challenges in maintaining accurate and reliable directories while building upon existing CMS regulations.

Beginning with Plan Year 2028, MA organizations must adhere to these updated requirements to ensure compliance. Key provisions include:

Validate Provider Data At Least Every 90 Days

MA plans are required to verify provider directory information at least once every 90 days. Previously considered a best practice with requirements for specific situations, this process is now mandatory under federal law.

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.

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 would read that information that the provider’s information may not be up to date.

Remove Non-Network Providers Within 5 Days

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.

Expanded Directory Data Criteria

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
Accommodations for People with Disabilities
Cultural And Linguistic Capabilities
Telehealth Capabilities

Annual Provider Directory Accuracy Analysis

MA organizations must conduct an annual analysis of their directory accuracy and report the findings to CMS.

Public Display of Accuracy Scores

Starting with plan year 2029, MA organizations must prominently display their provider directory accuracy score in the directory. These scores will also be publicly available on a CMS-maintained website to improve transparency for beneficiaries.

For more information on these requirements, read The REAL Health Providers Act Signed Into Law: New Provider Directory Accuracy Requirements for Medicare Advantage.

CY2026 Final Rule: New Provider Directory Requirements for Medicare Plan Finder

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

You must confirm the accuracy of your 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 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: Develop a process for maintaining audit-ready documentation to track which providers have validated their information and which have not. This approach supports compliance and simplifies reporting efforts.

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, compliance requirements, and strategies for success.

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.

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Proven Solutions for Your Provider Network Management

Looking to simplify your workload? Let Quest Analytics® take on the heavy lifting! Our solutions and dedicated team specialize in provider data accuracy and provider network adequacy for various lines of businesses, including Medicare Advantage, Medicaid and Commercial. Schedule a strategy session today and see how we can help you every step of the way.

Start a Conversation Today!

Efficiency on Autopilot: QES Volume Provider Network Reports and Analytics

Quest Analytics — Fri, 06 Feb 2026 09:31:58 +0000

Reports may not be the most exciting part of the job, but they are essential for success in provider network management. In this field, visibility is crucial, and having quick access to accurate information enables timely, informed decisions that drive operational excellence.

The Limitations of Manual One-Off Report Generation

Traditional manual processes often fall short of delivering the level of visibility required for effective decision-making. Manual report generation not only restricts accessibility but also impedes the flow of critical information within your organization. As a result, you risk losing out on precious time and opportunities.

Volume Reporting: Going Above and Beyond

Volume reporting, exemplified by Quest Enterprise Services® (QES) Volume Reporting, goes above and beyond the limitations of traditional manual approaches. It offers several advantages that can transform your provider network management processes.

Effortless Report Creation: Generate reports for all plans and service areas with a single workflow.

Seamless Report Sharing: Once you’ve created your report, you can share it with your team directly from within Quest Enterprise Services.

Comprehensive Overview: Automatically combine reports to create a holistic view of your networks.

Deeper Data Insights: Analyze extensive datasets quickly to identify hidden opportunities, make informed decisions, and drive better outcomes.

Volume Reporting In Action

Let’s take a quick look at how QES Volume Reporting can work its magic.

Imagine managing 30 Medicaid networks and needing to generate weekly Network Adequacy Summary by County reports for each network. In the past, this would have involved hours of manual report combining and distribution. With QES Volume Reporting, you can easily combine all 30 reports into one output.

The Future is Efficient, Precise, and Scalable

Volume reporting and analytics, such as QES Volume Reporting, are transforming provider network management, offering efficiency, precision, and scalability. By using these advanced tools, you can work smarter and focus on driving growth.

Want to learn more about QES Volume Reporting and how it can enhance your provider network reports and analytics? Schedule a complimentary strategy session today.

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Power Up Your Provider Targeting Strategy in Three Easy Steps

Quest Analytics — Fri, 06 Feb 2026 09:08:03 +0000

Building and maintaining a healthcare provider network is a cornerstone of operational success for healthcare organizations. Each provider you bring into your network has the potential to impact multiple business lines and healthcare delivery channels, making evaluation a critical yet often complex process.

Traditional, manual approaches to analyzing provider impact come with challenges. From sifting through massive amounts of data to piecing together how each provider fits into the larger picture, these methods demand significant time, resources, and effort—all of which can slow progress and increase costs.

If you’re looking to streamline this process and make more informed decisions with greater efficiency, Quest Enterprise Services® (QES®) Volume Targeting provides new ways for you to approach provider network management.

Why You Should Use QES Volume Targeting

Provider network modeling is a valuable approach when you’re looking to achieve growth and efficiency. Pursuing providers on a whim isn’t always the most effective way to reach your goals. With this QES Volume Targeting, you can simultaneously analyze potential providers across all lines of business to quickly understand their impact on your various networks.

Here are three reasons to use QES Volume Targeting:

Save Time Analyzing Providers
Ensure Value With Each Provider
Maintain Compliance With Network Adequacy Requirements

Save Time Analyzing Providers

Recruiting a provider is a significant investment and manually analyzing each potential provider can be tedious and time-consuming. With QES Volume Targeting, you can analyze how one or multiple providers will impact your networks simultaneously, saving valuable time and resources.

Ensure Value with Each Provider

It’s not enough to simply add providers to your network. You want to make sure that each provider you add helps you move the needle and brings value to your network. You want to ensure that each addition helps your business grow. QES Volume Targeting enables you to quickly analyze potential providers and determine that they are the right fit for your business.

Maintain Compliance with Network Adequacy Requirements

Maintaining compliance with network adequacy requirements is essential for your success. Failure to comply can result in sanctions such as heavy fines and contract terminations. With QES Volume Targeting, you can analyze your network and ensure that each provider you add to your network meets compliance standards, saving you from any legal or financial repercussions.

How to Analyze Your Provider Network in 3 Easy Steps

Here’s how to analyze potential providers for your networks with QES Volume Targeting, in three simple steps.

Step #1: Select Your Networks

Start by selecting the provider networks you want to analyze with QES Volume Targeting.

Step #2: Upload Your List of Providers

Next, upload a list of providers you’re considering adding to your network.

Step #3: Create Your Report

Finally, create your report to get instant insights into how each provider will affect your network.

Discover the Power of QES Volume Targeting

Take the time-consuming manual efforts out of provider targeting processes and see how QES Volume Targeting can help your network management. With its automated targeting process, you can remain compliant and competitive in your marketplace. Start using QES Volume Targeting today and simplify your provider targeting process.

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Looking to simplify your workload? Let Quest Analytics take on the heavy lifting! Our solutions and dedicated team specialize in provider data accuracy and provider network adequacy for various lines of businesses, including Medicare Advantage, Medicaid and Commercial. Schedule a strategy session today and see how we can help you every step of the way.

Start a Conversation Today!

Medicare Advantage Network Applications: What You Need to Know for CY 2027

Quest Analytics — Mon, 02 Feb 2026 09:00:09 +0000

If you’re gearing up for the Contract Year (CY) 2027 Medicare Advantage (MA) application process, this is your guide. Whether it’s understanding key dates, staying ahead of new network adequacy standards, or perfecting your submission, we’ve got insights to help you succeed. Let’s dive in and make sure you’re fully prepared.

Key CY 2027 Application Deadlines

Managing the application process begins with knowing the key CMS deadlines. Missing these can compromise your ability to enter the Medicare Advantage space or expand existing services. Here’s a quick look at some of the important dates to keep on your radar for the CY 2027 Notice of Intent to Apply (NOIA) and MA and Prescription Drug Benefit (Part D) application cycle.

January 7, 2026: CY 2027 MA and Part D Applications posted on CMS websites.

January 23, 2026: Final day to submit NOIA for CY 2027.

February 11, 2026: CY 2027 MA and Part D Applications Submission Deadline. All materials and supporting documentation must be submitted through HPMS.

For more information, refer to the CMS Memo from November 4, 2025.

What's New? Network Adequacy Updates for CY 2027 Applications

For the CY 2027 applications, CMS has introduced a few updates:

Network Adequacy Exception Requests: You can submit your requests during all 3 HSD Rounds. Learn more about Medicare Advantage Network Adequacy Exceptions.
New Facility Specialty Type: Outpatient Behavioral Health. Learn more about this specialty type and how it impacts your application.
Letters of Intent: New operational instructions for network submissions are provided. Read our guide on using Letters of Intent.

📝 As CMS releases additional guidance on MA network submissions, we will update this section.

CMS Network Adequacy Submission and Review

HSD Table Submission

To apply for an initial contract or service area expansion, you must demonstrate that your proposed provider network meets network adequacy requirements for providers and facilities within the designated time and distance standards. Here’s what you need to know:

Submit Health Service Delivery (HSD) Tables: Your provider and facility HSD tables must be uploaded to the Network Management Module (NMM) of the HPMS. CMS will review these tables to determine if the provider network meets the requirements.
Two Separate HSD Tables: Remember, you must upload two separate HSD Tables—one for contracted providers and one for contracted facilities.
Timelines: The network must be adequate a year before it goes live. As a result, CMS allows two allowances.

P.S. If you prefer video, watch this YouTube Video instead.

Medicare Advantage Application Changes

Scott Westover, SVP of Network and Regulatory Strategy at Quest Analytics®, explains what the new network adequacy rules mean for Medicare Advantage Organizations.

Two Application Allowances

Building a compliant network a year ahead of the contract year is no small feat. Recognizing the time and effort required, CMS offers two allowances to help you meet network adequacy requirements during the application process.

Application Allowance 1: 10% Application Credit

Applicants can leverage the 10-percentage Point Credit towards the percentage of beneficiaries residing within the published time and distance standards for new or expanded service area applicants.

It’s important to note that the Application Credit only applies during the application process. Once the contract is live, the credit will no longer apply. You must meet full network adequacy requirements for the entire service area, beginning January 1 of the contract year.

Key Takeaways: Using the Application Credit

The 10% credit will be automatically applied in HPMS and reflected on the MA organization’s Automated Criteria Check report.
The 10 percent credit is in addition to other credits such as the Telehealth or Certificate of Need (CON) credits, if applicable.
Once the contract is live, the credit will no longer apply.
The MA organization must meet full network adequacy requirements for the entire service area, beginning January 1 of the contract year.

💡 Tip: Use Quest Enterprise Services® Medicare Advantage 10% Credit for Application Counties to quickly assess network adequacy for your proposed counties with the new 10% application credit today.

Application Allowance 2: Letters of Intent to Contract

Applicants can use a Letter of Intent (LOI) to contract in place of a signed provider contract during the application phase to meet network standards. The intention is to give initial applicants and those seeking to expand into a new market the opportunity to reach the threshold for network adequacy while still finalizing contract details.

Important Considerations for MA organizations Using Letters of Intent

When using a Letter of Intent, it’s important to keep two key aspects in mind.

Conversion into Full Contract by January 1

Ensure that Letters of Intent are fully executed contracts before January 1, of the go-live date.

Participation in the Triennial Review

When you use Letters of Intent for the application of a new or expanded service area you must participate in a CMS Triennial Network Adequacy Review the first year the plan is operational in its new service area.

Key Takeaways: Using Letters of Intent

The Letter of Intent is only for Initial or Service Area Expansion counties.
You want to have a process and plan to assess your network for compliance regularly and after every mid-year termination.
Don’t underestimate the effort and time required to convert to a full contract.

💡 Don’t Miss Out: Quest Enterprise Services® Adequacy supports you with the Letter of Intent field for the Provider and Facility Tables.

3 Steps to Help You Prepare for Your Medicare Advantage Application

To stay organized and on schedule, here are three key steps to help you prep your MA application.

Step #1: Review and Validate the Provider Network

Before your network submission, you want to review your data to make sure you don’t have any network adequacy gaps. Pay special attention to the new behavioral health specialties in your HSD tables. Make sure they’re accurately listed and that your network meets the requirements for network adequacy.

Step #2: Ensure HSD Tables Match Provider Directories

To avoid data discrepancies or compliance issues, ensure that your provider directories and HSD tables match. Take the time to compare and cross-check the data in both sources. This way, you can be confident that your provider directories accurately reflect the information listed in your HSD tables.

Step #3: Limit Provider Locations in HSD Tables

To align with CMS guidelines, limit each provider to a maximum of 10 locations. Include only the locations where members can regularly schedule appointments. Exclude locations where the provider is a substitute or temporarily stationed.

💡Tip: Use Quest Enterprise Services® (QES®) Accuracy to identify the locations where providers are actively seeing members.

Maximize Your Service Area Expansion Goals with Quest Enterprise Services®

Responding to the changes introduced by CMS is essential for the continued success and growth of your Medicare Advantage products. Effectively navigating these regulatory updates enables strategic expansion while maintaining high standards of provider accessibility and patient satisfaction.

Quest Enterprise Services® (QES®) supports your strategic initiatives by providing an innovative platform to streamline your expansion and application processes. With our industry-renowned Network Adequacy template, Network Adequacy Exceptions Package, and Provider Data Accuracy tools, QES is your partner in building and maintaining compliant, sustainable provider networks. Contact us today and discover how our solutions and team can help you achieve your goals.

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Elevate Your Provider Network Management Process

Quest Analytics — Thu, 29 Jan 2026 00:47:16 +0000

Quest Enterprise Services Scenario Modeling Package

Wouldn’t you love to get more time back into your busy day? The Quest Enterprise Services® (QES®) Scenario Modeling Package can help you maximize every minute when managing multiple provider networks. With its powerful automation, you can quickly understand the impact of large-scale provider contracting or termination across multiple lines of business, making it easier to compare current and projected networks. You can also view and share this critical information with key stakeholders in a flash. You might be surprised by how much this package improves your daily routine.

What is the QES Scenario Modeling Package?

The QES Scenario Modeling Package combines three powerful tools: Volume Terminations, Volume Targeting, and Volume Reporting. Together, these tools help you stay ahead in today’s dynamic market while also ensuring that your networks are compliant with ever-changing regulations. Here’s how:

Volume Terminations streamlines your provider termination strategy, giving you complete visibility into the impact of removing providers from multiple networks all at once. With its efficient and fast process, you can take a proactive approach toward provider termination, network adequacy compliance, and network maintenance strategies.
Volume Targeting provides a swift and straightforward way to build and maintain provider networks that meet your needs. With a few simple clicks, you can find out if prospective providers or provider groups can help you reach your coverage goals. Not only does this save you valuable time, but it also ensures that the providers you target to contract with can help meet compliance requirements.
Volume Reporting automates your report-generating process for all or select provider networks, freeing up hours of your time so you can focus on making strategic decisions that will propel your business forward. With Volume Reporting, accessing the right data and distributing it to necessary stakeholders is easy and efficient, giving you the context to make the most informed decisions quickly.

What Can QES Scenario Modeling Do For Your Provider Network Management Process?

Enhance Business Operations and Strengthen Market Presence

The QES Scenario Modeling Package provides you with the power to create compliant and compelling provider networks. By automating manual processes, you can drastically reduce the amount of time it takes to plan and manage your provider networks. With the help of automated what-if scenarios and data-driven insights, you can make informed decisions to skillfully manage your provider network and give your organization the upper hand. Plus, all your provider network activities can be monitored in one place—simplifying network and data management tasks.

Take your provider network management to the next level with the QES Scenario Modeling Package. Schedule a strategy session today to see how it can support your goals.

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Turbocharge Your Provider Network Management

Quest Analytics — Tue, 27 Jan 2026 00:01:41 +0000

Managing a healthcare provider network requires constant visibility into network analytics and strategic decision-making. QES Volume Terminations simplifies this process by automating network scenario modeling, allowing you to quickly analyze the impact of removing providers from multiple networks simultaneously. By reducing manual tasks and delivering rapid, actionable insights, automation helps you make better decisions and focus on high-impact initiatives.

What is QES Volume Terminations?

QES Volume Terminations helps you analyze provider impacts and gain insights in key areas, including:

Network Impact: Evaluate the effects on members, lines of business, coverage, and compliance
Strategic Gaps: Identify potential gaps created by provider terminations
Provider Details: Understand key attributes like specialty, practice locations, and contracted networks.

Automation and powerful analytics are at the core of helping you plan for growth and success with your provider networks. The ability to quickly evaluate the impact of removing a provider or provider group across Medicare Advantage, Medicaid, and Commercial networks drives efficiency and informed decision-making.

Think of it as having a crystal ball for provider network management. With enhanced speed, precision, and analytics, this tool offers a transformative approach to strategic planning. Let’s explore how it can turbocharge your provider network management practices.

What Can QES Volume Terminations Do For Your Provider Network Management?

Powerful Network Analytics for Proactive Scenario Modeling

Using our advanced analytics, QES Volume Terminations enables you to evaluate the impact of removing National Provider Identifiers (NPIs) or Tax Identification Numbers (TINs) across all your provider networks and lines of business — simultaneously.

In just four simple steps, you gain actionable insights to make informed decisions:

Identify affected specialties, counties, and lines of business to understand how provider terminations will influence your network.
Determine the number of gaps created within networks where the provider participates, helping you spot potential challenges.
Review and compare network adequacy scores for both current and projected networks, ensuring alignment with regulatory and business requirements.
Plan with confidence, thanks to fast and accurate scenario modeling that eliminates guesswork and supports strategic decision-making.

Tip: Use QES Volume Targeting to identify providers who can fill potential gaps before termination decisions take effect.

Avoid Compliance Hurdles

QES Volume Terminations doesn’t just save time—it also simplifies compliance management. Advanced automation helps you proactively identify gaps resulting from provider terminations, giving you the insights needed to act ahead of time to make informed decisions that ensure compliance with regulatory standards while minimizing risks.

With QES Volume Terminations, you can answer key network adequacy questions such as:

What would my network look like if I removed providers who haven’t recently attested to their information?
What would my network look like if I removed providers who have more than 10 locations?
What would my network look like if I removed all the ghost providers?

Having the ability to anticipate and address compliance issues before they arise empowers you to manage networks thoughtfully and strategically, protecting your organization from penalties and operational disruptions.

Negotiation with Powerful Insight

Negotiations can be tricky, but with QES Volume Terminations, you’ll have a wealth of insight at your fingertips. You’ll be equipped with the analytics to see just how much weight they carry when it comes to contributing to your network. Can you picture yourself walking into that negotiation, head held high, armed with the knowledge you need to make the best decision for your organization? No more hesitating or second-guessing the conversation, you’ll have the data and insights to back up your decisions.

Manage Your Provider Network with Ease and Efficiency

QES Volume Terminations is a must-have for any healthcare network looking to thrive. With this highly effective tool, you’ll have the power to manage your healthcare provider network with ease and efficiency, ensuring maximum value to all stakeholders.

Get ready to simplify your network management—and your work day—with just a few clicks. QES is an easy-to-use network solution that enables you to make faster, smarter, more strategic decisions. Discover what QES Volume Terminations can do for your organization today.

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Understanding CMS Exception Requests for Network Adequacy

Quest Analytics — Mon, 19 Jan 2026 09:35:05 +0000

Raise your hand if you’ve ever had difficulties meeting network adequacy criteria. Well, you’re not alone. Submitting an exception request for network adequacy involves multiple components, and we’re here to guide you through the process.

What is Network Adequacy?

Medicare Advantage Organizations (MAOs) must comply with network adequacy standards in every county they operate in. These criteria are in place to ensure that MAOs have sufficient doctors, hospitals, and healthcare specialists available to provide timely and appropriate care to their members.

Demonstrating Compliance: Network Adequacy and HSD Tables

MAOs must demonstrate that their provider network meets the network adequacy requirements for the number of primary care providers (PCPs) and specialists within the designated time and distance standards. To fulfill this requirement, MAOs need to submit their provider and facility Health Service Delivery (HSD) tables to the Network Management Module (NMM) of the Health Plan Management System (HPMS). CMS will review the HSD tables to determine if the provider network meets the requirements.

Tip: Read CMS Changes in the Network Adequacy Application Process for Medicare Advantage Organizations to learn more about the MAO application process.

Why Submit an Exception Request?

When MAOs can’t meet network adequacy standards, they may be allowed to submit an exception request to the Centers for Medicare & Medicaid Services (CMS). An exception request allows organizations to explain their inability to meet the published network adequacy criteria. Typically, MAOs use the exception process when the supply of providers or facilities is scarce, making it impossible for them to obtain contracts that meet CMS’s network adequacy criteria.

TIP: Use our FREE checklist to create a compelling case for your network adequacy exception request. This checklist guides you through the process, ensuring you have all the required details for a successful request. Download your checklist now to get started!

Exception Requests Checklist

When Can Medicare Advantage Organizations Request an Exception to Network Adequacy Criteria?

MAOs can request an exception to network adequacy criteria when both of the following conditions occur.

Condition 1: Certain providers or facilities are not available for the MA plan to meet the network adequacy criteria as shown in the Provider Supply file for the year for a given county and specialty type.

Condition 2: The MA plan has contracted with other providers and facilities that may be located beyond the limits in the time and distance criteria but are currently available and accessible to most enrollees, consistent with the local pattern of care.¹

What are Valid Rationales for Submitting Exception Requests?

MAOs may request exceptions to network adequacy criteria under certain circumstances. Some examples of valid reasons for an exception request.

Provider No Longer practicing: If a provider has retired, passed away, or simply stopped practicing.

Exclusive Contracts: If a provider exclusively contracts with another organization and not with the MAO seeking an exception.

Mismatched Service Details: If a provider’s listed address or specialty type doesn’t match what they offer.

Opt-Out of Medicare: If a provider has opted out of Medicare.

Sanctioned Providers: If a provider is listed on the List of Excluded Individuals and Entities.

Apart from the valid reasons mentioned above, there are a few more rationales an organization can utilize for exception requests:

Pattern of Care: The organization can provide evidence demonstrating that the contracted network meets or exceeds the original Medicare pattern of care.

Telehealth: The organization may use telehealth to meet healthcare access requirements, as long as it is provided in a manner consistent with original Medicare.

Mobile Providers: If an organization utilizes Mobile Providers, they must be qualified and deliver services on a scheduled basis.

Network Adequacy Exception Rationales for Facility-Based I-SNP

In a move to address specific challenges faced by facility-based Institutional Special Needs Plans (I-SNPs), CMS has introduced two new network adequacy exceptions. This includes exceptions for situations where I-SNPs are unable to contract with required specialty providers and when they can provide basic benefits predominantly through telehealth services.

What are Invalid Rationales for Submitting Exception Requests?

In contrast, there are a few things that CMS doesn’t consider valid reasons for an exception request.

Inability to Establish a Contract: The inability to successfully negotiate and establish a contract with a provider or facility.

Failure to Reach a Financial Agreement: The inability to come to a financial contracting agreement with a provider or facility.

Reluctance to Cross State or County Lines for Contracting: The organization does not want to cross state or county lines to contract with a provider or facility.

How to Submit an Exception Request?

Now, that we’ve talked about the why and when of exception requests, let’s unpack the how. MAOs must adhere to two key elements in line with CMS’s guidelines when requesting an exception:

Complete the Medicare Advantage Health Service Delivery Exception Request Template accurately.
Provide compelling and data-backed evidence.

Tip: Have information on both contracted and non-contracted providers at hand. This will help fulfill these essential criteria more efficiently.

What's the Timeline for Exception Requests?

The submission timeline includes stages of application, deficiency response, and potential exception review, concluding with final notification of the application’s success or denial. Each step, from the initial HSD table submission to the response to any Notice of Intent to Deny (NOID), must be conducted within specified CMS timeframes.

Network Adequacy Exception Request Success

While an exception request approval is a significant achievement, it’s not a lifetime guarantee. Each year, MAOs must submit an exception request. It’s like an annual membership renewal but for your network adequacy exception. Discover how a health plan reduces, expedites, and enhances network exception requests with Quest Enterprise Services® Exceptions.

How Does CMS Evaluate Exception Requests?

Once an exception request is submitted, CMS evaluates each request on a case-by-case basis. They consider factors such as the impact on beneficiaries’ access to care, the availability of alternative options for essential services, and the credibility and thoroughness of the MAO’s request. Based on this evaluation, CMS may approve the exception request if it meets the required criteria, request additional information or modifications, or deny the request.

5 Best Practices for Filling Out the MA HSD Exception Request Template

To improve your chances of success, here are five tips for completing the Medicare Advantage HSD Exception Request Template.

Use the correct naming convention when saving the template, including the Contract Number, SSA code, and HSD Specialty Code.
Enter provider information into the designated sections, rather than submit it as an attachment.
Include specific data sources and respond to each question in the template.
Use the correct contract ID when submitting requests for multiple contracts.
Use Adobe Acrobat to fill out the Exception Forms to ensure compatibility.

Streamline Network Adequacy Exception Requests

Instantly generate CMS Medicare Advantage Network Adequacy Exception request documents. See how the QES Exceptions Package can transform your workflow.

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Ghost Networks in Healthcare: What They Are and How To Address Them

What is a Ghost Network?

What Causes a Ghost Network?

1. Provider Data Accuracy Challenges

2. Varied Provider Directory Requirements

3. Difficulty Integrating Data Updates

4. Employee Turnover and Shifting Initiatives

What are the Implications of Ghost Networks?

Regulatory Attention on Ghost Networks

New Federal Legislation

Requiring Enhanced & Accurate Lists of Health Providers Act

Proposed Federal Legislation

Behavioral Health Network and Directory Improvement Act

States Fighting Ghost Networks with Requirements

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Invest in an Enterprise Provider Network Management Solution

Enhance Provider Verification to Improve Provider Data Accuracy

Prioritize Solutions that Promote Seamless Cooperation between Teams

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The REAL Health Providers Act Signed Into Law: New Provider Directory Accuracy Requirements for Medicare Advantage

New Medicare Advantage Provider Directory Accuracy Requirements

1. Verify Provider Data Every 90 Days

2. Indicate Unverified Providers in the Directory

3. Remove Non-Network Providers Within 5 Days

4. Expanded Provider Directory Information Criteria

Annual Provider Directory Accuracy Analysis and Reports

1. Conduct Directory Accuracy Analysis

2. Submit a Report to HHS

Public Display of Provider Directory Accuracy Scores

Upcoming CMS Guidance Updates

The Latest Medicare Advantage Provider Directory Requirements

Time to Prepare: How Quest Analytics Can Help MA Plans

How QES Accuracy Positions You for Success:

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The Latest Medicare Advantage Provider Directory Requirements

New: The REAL Health Providers Act Introduces New Provider Directory Accuracy Requirements for Medicare Advantage

Beginning with Plan Year 2028, MA organizations must adhere to these updated requirements to ensure compliance. Key provisions include:

Validate Provider Data At Least Every 90 Days

Indicate Unverified Providers in the Directory

Remove Non-Network Providers Within 5 Days

Expanded Directory Data Criteria

Annual Provider Directory Accuracy Analysis

Public Display of Accuracy Scores

CY2026 Final Rule: New Provider Directory Requirements for Medicare Plan Finder

The New Medicare Advantage Provider Directory Requirements You Need to Know

Special Election Period for Incorrect Medicare Plan Finder Information

Existing Medicare Advantage Provider Directory Requirements

1. Online and Printed Directories

2. Searchable Provider Directories

3. Provider Verification

Provider Directory Data Elements

CMS also encourages plans to incorporate the following information about providers into the provider directory, as practicable:

4. Update Directory Information in 30 Days

5. What Medicare Advantage Plans Cannot Do

How CMS Monitors Compliance

FAQs

Who is Responsible for Directory Errors?

Where can MA plans find guidance on required provider types for inclusion in directories?

Which providers should be listed in the directory?

What are the rules about listing practice locations for providers?

How do I ensure provider specialties are accurately represented?