Back to Insights and Updates for ProvidersMarch 2024

CMS Medicare Advantage provider directory audits

Point32Health Medicare Advantage/Senior Products

Provider directories are an important resource for health care consumers, who rely on them to make informed decisions regarding their health care choices.

It’s important that providers assist in efforts to maintain accurate and up-to-date information in provider directories, because inaccuracies can create barriers for members to receive services critical for their health and well-being.

To that end, and in accordance with the Consolidated Appropriations Act of 2020, the Centers for Medicare and Medicaid Services (CMS) conducts Medicare Advantage online provider directory reviews. We recommend that providers in our Harvard Pilgrim Health Care and Tufts Health Plan Medicare Advantage/Senior Products network assign someone in your office to be responsible for managing activities related to provider directory information, as you may receive outreach from CMS in connection to an audit and it’s crucial that you’re prepared to address any questions they may have.

Be prepared: questions CMS is likely to ask

Point32Health deeply values our exceptional providers and we’re committed to supporting you however we can. To set you up for success in the event of an outreach call from CMS, we want to ensure that you have an opportunity to review the information you’re likely to be asked about. In this Online Provider Directory Review Report issued by CMS, you can find the questions that are typically associated with these audits.

Should your office receive a call from a patient or CMS regarding provider directory information, we encourage you to forward the call to your designated associate to respond to the inquiries, which may include (but are not limited to):

  • Does the provider see patients at this location?
  • Does the provider accept Medicare Advantage Prescription Drug plans at this location?
  • Does the provider accept new patients who have a MA-PD plan? (The provider directory is considered accurate if it correctly indicates the provider is or is not accepting new patients.)
  • What is the telephone number for making appointments? (Usually confirmed by dialing the phone number.)

Refer to the CMS Online Provider Directory Review Report (pages 10-11) for a more extensive list of questions that may be asked to determine directory accuracy.

Please be aware that providers who do not respond to verification requests from CMS may face delayed claim reimbursements and removal from provider directories.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

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