Provider directory accuracy, checked against claims: every listing tested, every correction approved by your analyst
Stale listings found and fixed before a member is sent to the wrong door.
See one case, screen by screen ↓Software that keeps a health plan’s provider directory right: it verifies each listing’s practice, address, phone, specialty, new-patient status and networks, finds the ones that have gone stale and gets them corrected. Provider Directory Accuracy does this by testing every listing against group rosters, paid claims and provider replies, with a provider data analyst approving each correction.
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A directory is only as good as what the offices tell you. Doctors leave groups, practices move, panels close and phones change — and the attestation comes back “no changes”, or does not come back at all. Rosters arrive late, each group in its own spreadsheet layout, and a departure is often just a row that quietly stops appearing.
So the team calls, faxes and chases, listing by listing, while the 90-day cycle runs and the 2-business-day clock starts the moment new information lands. Meanwhile a member opens the directory, picks a cardiologist who has not worked at that address for a year, and calls member services — or files a grievance. Federal reviewers treat that as an access failure, and a listing like it makes a network look adequate when it is not.
Estimated split for one listing in conflict, worked by hand and with the solution, in days.
Six agents test every listing against rosters, claims and replies; the provider data analyst approves each correction.
Dr. Miriam Castellanos is listed as a cardiologist at Northfield Heart Associates in Dayton, accepting new patients, in three Harborline networks. Here is what happens to that listing, screen by screen, in the working solution.
Dana opens her queue: day 12 of the Q4 cycle, 2,384 open conflicts, 612 likely ghosts. The queue is grouped by kind of conflict, with the most-viewed listings first. At the top is listing L-20417, Dr. Castellanos, with an accuracy score of 22 and 31 member views in 90 days. The card puts the directory beside the group roster, the claims and the last attestation, field by field.
“No claims at this address in 12 months. Her group dropped her from its roster without a termination notice, and the last attestation said ‘no changes’ 487 days ago.”
Dana opens the claims detail for NPI 1487263950. Nine claims at 2200 Kettering Blvd in August 2025, then nothing. From November 2025 the same NPI bills at 7700 Camargo Rd, Cincinnati, under Lakeside Cardiovascular — a group Harborline does not contract with — climbing to 50 claims in September 2026.
“24 months · paid through 30 Sep 2026 · counts only, no member detail”
Dana presses Re-check and watches each step land. The roster reader finds her absent from Northfield’s September roster, last present in June. The source matcher sees the national registry moved her to Cincinnati on 14 Nov 2025, while the credentialing file still says Dayton. The accuracy scorer gives 22 out of 100 at CMS weight 3: should not be listed at this location.
Correction drafter: “Remove this location from 3 networks; one request to Northfield; recruiting note to the network manager. Waiting for you.”
Northfield’s September roster came in as a 14-column spreadsheet with 64 practitioners. The roster reader found nine changes: six confirmed by claims, three that need a person. Dr. Castellanos is missing for the third month running; Dr. Paul Ferreira is missing from September only, yet billed 61 claims there that month — likely a roster error.
Roster reader: a missing row is reported, not acted on.
Both open Northfield questions go in a single request to the practice manager, by provider portal and email. It names the rosters each doctor is missing from and what claims show at the address, with claims by month attached as counts only. Follow-ups go out on day 7 and 14.
“One reply covers both. Until we hear back, Dr. Castellanos’s Dayton listing is removed so members are not sent there.”
The correction drafter proposes the smallest correct change: remove 2200 Kettering Blvd from Advantage HMO, Advantage PPO and Medicaid, ask Northfield to confirm (VR-26-11834), send a recruiting note to Marcus Bell, and link grievance G-26-04417. Montgomery County cardiology goes from 41 to 40 listed cardiologists against a plan standard of 34. The margin stays above 10%, so Marcus is told but does not need to approve.
“Members see the change by Wed 14 Oct — within 2 business days. Approved by Dana Whitfield, provider data analyst.”
Dana presses Approve and publish. The removal is set for all three networks, publishing by Wed 14 Oct, and Northfield is asked to confirm. Dr. Castellanos is marked done in her queue at 10:42. Next is Dr. Grace Okonkwo, a pediatrician with no claims at her Dayton address since July 2025.
“Removed from 3 networks · publishes by Wed 14 Oct · Northfield asked to confirm (VR-26-11834)”
The removal is at the top of the history: Mon 12 Oct 10:42, the evidence behind it, Dana as approver, and the date members stop seeing the listing. Group replies, nightly claims runs and member inquiry answers sit in the same log, kept for 2 years.
Every listing is tested against 24 months of paid claims for its NPI, address and tax ID. At the 12-month line, 612 listings are likely ghosts, mapped by specialty and county — physical and occupational therapy and behavioral health in Franklin County lead. New providers, hospital-based specialties and telehealth-only providers are left out of the test.
Each plan’s directory carries a weighted deficiency score using the CMS review method, a quarterly mock review of 108 providers per plan, and the 90-day cycle: 91.3% verified, 1,207 listings past 90 days. Corrections this cycle were published in a median 0.8 business days, 99.6% inside the 2-business-day clock.
The same listing, seen by the four people who carry it — what their week looked like, and what it looks like now.
Six agents test every listing against rosters, claims and replies; the provider data analyst approves each correction.
Reads group rosters in any layout — spreadsheets, PDFs, emailed tables, portal uploads — and compares every row with the directory: adds, departures, moves, phone changes and practitioners who silently disappeared.
Tests every listing against 24 months of paid claims by NPI, service address and tax ID — finds ghost listings, moves, closed panels and telehealth-only practice.
Compares each listing with credentialing, the national provider registry and state license boards.
Sends one verification request per group with the evidence attached, follows up on day 7 and 14, and reads replies from the portal, email and fax.
Scores each listing 0–100 and each plan with the weighted deficiency method CMS uses in its directory reviews.
Turns the evidence into the smallest correct change — remove a location, move it, change the phone, set the panel flag — with its network effect and publish deadline, for a person to approve.
Approves; network manager when adequacy is at stake. The agents propose; a named person decides.
Ask about any listing, roster, request or plan — or tell it what to draft. Every answer cites the claims, roster or request it rests on.
Why is Dr. Castellanos flagged as a likely ghost?
Three sources disagree with the directory. Claims: no claims at 2200 Kettering Blvd since 21 Aug 2025, and 412 at Lakeside Cardiovascular in Cincinnati since 3 Nov 2025. Roster: Northfield dropped her after June 2026, with no termination notice. Attestation: “no changes”, 487 days ago. 31 members saw the listing in 90 days and one filed a grievance.
Which Montgomery County cardiologists have no claims in 12 months?
7 listings in Montgomery County cardiology are over the 12-month line, out of 41 listed cardiologists. The two most seen by members: Dr. Miriam Castellanos (31 views) and Dr. Jonah Whitaker (6 views). Removing all 7 would leave 34 — exactly the plan standard of 34 — so once the margin falls under 10% the network manager decides.
Are we inside the 90-day cycle for the Medicare Advantage directories?
Mostly. 92.0% of Advantage HMO and 91.1% of Advantage PPO listings were verified in the last 90 days. Plan-wide, 1,207 listings are past 90 days; 2,989 more are due within 14 days with requests already out.
Draft one request to Northfield Heart Associates with the evidence
Done — one request covering both open Northfield items: Dr. Castellanos (no claims here in 12 months, missing from three rosters) and Dr. Paul Ferreira (missing from September only, still billing). Claims summaries are attached, member details are not. Review it and press Send.
13 screens from the working solution, on its sample data. Pick one to see it large.
The ghost test, the clocks and the approvers are settings — each change saved as a new version.
| Setting | Default | Choose from |
|---|---|---|
| Flag a likely ghost after no claims at the listed address for | 12 months | 6 · 9 · 12 · 18 · 24 months |
| Panel test: no new-patient visits (99202–99205) for | 6 months | 3 · 4 · 6 · 9 months |
| Leave out new, hospital-based and telehealth-only providers | On | On · Off, each |
| Verify every listing at least every | 90 days | 60 · 75 · 90 days |
| Hide if unverified after outreach of | 30 days | 14 · 21 · 30 · 45 days |
| Publish a correction within | 2 business days | 1 · 2 business days |
| Rosters due by | The 5th | 3rd · 5th · 10th of the month |
| Removals that cut a county margin below 10% | Network manager | Any named approver |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample directory data · “estimated” = our estimate · “typical” = published figures: CMS Online Provider Directory Review, round 3 (Nov 2018) — 48.74% of locations with at least one inaccuracy; 42 U.S.C. § 300gg-115 (No Surprises Act directory provisions) — verification at least every 90 days and updates within 2 business days. People, plans, practices and providers named on this page are fictional — characters and sample data in the working solution.
Software that keeps a health plan’s provider directory right: it verifies each listing’s practice, address, phone, specialty, new-patient status and networks, finds the ones that have gone stale and gets them corrected. Provider Directory Accuracy does this by testing every listing against group rosters, paid claims and provider replies, with a provider data analyst approving each correction.
The claims activity checker counts paid claims for each NPI at the listed service address, month by month for 24 months, and at every other address and tax ID. A listing with no claims at its address past the threshold — 12 months by default — is flagged as a likely ghost. Low volume alone is never treated as proof, and new, hospital-based and telehealth-only providers are left out.
It tracks both. Every listing carries its last verification date, the plans screen shows how many are verified within 90 days and how many are past it, and each correction carries its publish deadline. In the working solution, corrections were published in a median 0.8 business days.
It contacts provider offices, never members. The outreach agent sends one request per group with the evidence attached, by portal, email or fax, follows up on day 7 and 14, and reads the replies. A listing still unverified after 30 days of outreach is hidden until it is.
Each proposed removal shows the county count before and after against the plan’s standard. A removal that cuts the county margin below 10% goes to the network manager to decide, and a doctor who moved to a non-contracted group comes with a recruiting note.
Yes. The agents read, score and draft; they never publish. A provider data analyst approves every change, the network manager approves adequacy-affecting removals, and every change is recorded with its evidence and approver.
Yes. The likely-ghost threshold, the panel test, the verification cycle, when unverified listings are hidden, the correction and member-inquiry clocks, roster due dates and the approvers are all settings. Each change is saved as a new version and applies from the next nightly run.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your directory rules, network standards and sample rosters and claims — and it goes live once every quality gate has passed. We will walk you through it on your own listings first.
Every criterion shown met or not met, with the page that proves it.
1-min demoUtilization Management AutomationNo missed 72-hour or 7-day deadline, and the yearly metrics from the same data.
1-min demoAppeals & Grievances ManagementEvery appeal decided on time, with the full file read and what is new marked.
1-min demoWe’ll run Provider Directory Accuracy on a sample of your own listings, rosters and claims.