How will the CMS National Directory affect health plans?

By Ron UrwongsePolicy and Regulation

CMS announced on June 3, 2025 plans to build a National Directory of Healthcare (NDH). While the directory’s long-term vision includes both consumer-facing provider information and interoperability-focused provider endpoints, CMS has stated that its initial focus will be on endpoints to support interoperability.

The federal government, as part of the 21st Century Cures Act, required providers and payers to make APIs available to present patient data, and additional APIs are being required over time. A national directory of these API endpoints has not yet been established, which would facilitate provider-payer, payer-payer, and provider-provider data exchange and would increase the utility of required APIs. That’s why CMS wants to focus on provider endpoints first. It will support accelerated use of the APIs it previously mandated.

Future use cases, beyond interoperability support, for the NDH include:

  • Provider search
  • Referral enablement
  • Credentialing and privileging
  • Health plan enrollment

These use cases carry major implications for payer strategies in interoperability, provider data management, and digital infrastructure. Payers should consider how to evolve their infrastructure and operations to adapt to a transformative National Directory. The remainder of this post explores the different ways a National Directory can affect health plans, what they should pay attention to, and immediate steps they can take.

1. Sourcing Provider Directory Data

CMS has suggested that NDH will eventually become an authoritative source for provider directory data, however, no timeline has been established, and the scope of any phase for the NDH is only hinted at.

  • Short term: The focus will likely be on API endpoints, not patient-facing directory fields like “accepting new patients”, “hours of operation”, or “services provided.”
  • Medium term: Basic demographic data (TINs, NPI, phone, address, practitioner-organization affiliations) may be incorporated to support endpoint matching and resolution.
  • Long term: Consumer-facing fields and operational attributes may come in a second or third phase.

Recommendations:

  • Continue using current provider data sources.
  • Monitor CMS roadmap announcements to align with upcoming data availability.
  • Take advantage of any NDH data that becomes available, even if limited to endpoints or affiliations.

2. Provider Endpoints Are Valuable Today

Do not wait for CMS to finalize NDH before investigating and using provider endpoints as they are available. FHIR API endpoints are already being published by providers and can enhance:

  • Quality measurement
  • Risk adjustment workflows
  • Value-based care (VBC) coordination

Work with vendor partners like Velox Health Metadata to assess provider endpoint coverage in your network and begin requesting access to and integrating with these endpoints to capture clinical data more efficiently. This is a great opportunity for forward-thinking health plans to inventory their clinical data channels, identify opportunities, and begin to take advantage of these opportunities.

Recommendations:

  • Inventory your clinical data sources and understand the true cost of managing them.
  • Explore the use of FHIR APIs as more efficient sources for clinical data.

3. Credentialing & Enrollment: Not Yet Displaced

NDH will not immediately replace payers’ existing sources of data for credentialing and network enrollment. Providers will not immediately be able to submit data exclusively to the NDH, and will still have to transmit rosters and credentialing applications to the tens of payers they are contracted with.

  • There are thousands of data elements involved in credentialing, from licensure to malpractice coverage.
  • CMS may eventually integrate PECOS into the NDH, and NDH could be a front door for any data submitted into PECOS. If and when this happens, and if CMS decides to make PECOS data available for industry use, then the NDH becomes a credible replacement for existing multi-payer industry portals (e.g., CAQH, Availity, and state-run Medicaid portals). This seems like a ‘Phase 3’ development.
  • This could similarly decrease the need for spreadsheet-based roster data exchange
  • If CMS and accreditation bodies (e.g., NCQA, Joint Commission) recognize NDH as an acceptable primary source, and if NDH integrates with primary sources, then payers could use NDH exclusively.
  • If and when this happens, a more efficient and affordable resource could finally enable the idea of ‘continuous credentialing’ instead of event-based credentialing.

Recommendations:

  • Monitor what credentialing data elements are incorporated into NDH
  • See if they are able to establish integration relationships with primary sources
  • Engage with accreditation bodies to understand their opinion of NDH as a primary source
  • Connect with your credentialing verification organizations (CVOs) to see how they plan on using NDH as it becomes available, or see whether they view it as a disruptive threat to their business

4. Provider Directories: Keep Fixing Them

Some payers wonder if the announcement of NDH allows them to deprioritize current provider directory compliance. The short answer: No. We aren’t certain of the future (detailed) scope of a National Directory, or the timelines for relevant phases. However, we do know that payer network data (and provider-plan relationships) will end up in the National Directory. What this means for payers:

  • NDH will allow CMS to cross-check payer directory data against provider-attested data.
  • NDH will improve data comparability across FHIR APIs, TiC MRFs, and HSD submissions.
  • CMS may use this to detect discrepancies, trigger audits, or enforce penalties.
  • CMS and other regulators will be paying more attention, not less, to the directories.

Recommendations:

  • Continue making investments in provider directory clean-up. Even outside of NDH, FHIR APIs and provider-published machine-readable data are now more prevalent. This is democratizing the ability for smaller payers in the market to affordably clean-up directory data. Some payers have taken advantage of this and have achieved > 70% accuracy directories. This is not the time to fall behind!
  • Focus especially on establishing an internal ‘source of truth’ within your organization that is able to efficiently master provider data coming from external sources
  • Improve measurability: Be able to explain where inaccuracies come from (e.g., provider group submissions vs. payer issues). This will allow you to provide constructive feedback to NDH when you detect errors in attested data (yes, you still want the data to be accurate and useful for your members. you do not want to be just a passive consumer of the data coming from NDH).
    • If you’re interested in learning about Defacto Health’s Provider Directory Risk Report and evaluating a free sample, to see how we can help you increase measurability, drop us a line!
  • Develop the ability to harmonize your data with NDH quickly. The NDH will be able to bring in payer directory data far sooner than it will publish the full scope of directory data for industry consumption. That means that as soon as NDH publishes that full scope, it will be able to immediately compare and contrast your directory data with what was attested to by providers in NDH.

5. Provider Directory APIs: Keep Fixing Them

Many payers still have non-functional directory APIs, even though the CMS requirement went into effect in 2021. These APIs will be the vehicle for linking providers with insurance plans in the NDH. CMS will want these to be working well enough to start importing the data into the NDH. As CMS increases its use of the APIs, they will likely increase activities around compliance monitoring and enforcement.

Recommendations:

  • Ensure the Provider Directory API includes accurate provider-plan relationships
  • Align API data with your own public web directories.
  • Make sure endpoints are queryable and FHIR-compliant.
  • Engage with Defacto Health for zero-cost assessment of your Provider Directory API

6. Network Adequacy Oversight Changes

CMS will gain another channel to measure network adequacy using NDH data: especially if provider-plan affiliations and service locations are included. This means that CMS and other regulators will be able to assess network adequacy more frequently and informed by richer and varied data.

Why it matters to payers:

  • This could eventually be a replacement for HSD table submissions, if NDH includes relevant data
  • Regulators may crosswalk NDH data against sanctions registries, attested data, other payer network data, and appointment availability data to develop novel availability-adjusted adequacy measures.
  • More granular data could lead to more rigorous enforcement of time-and-distance rules or essential community provider requirements.

Recommendations:

  • Audit the alignment between your HSD tables and your provider directories.
  • Ensure the ability to adapt network management processes to use NDH data.
  • Prepare for external comparisons against NDH-derived “ground truth.”

7. Transparency Will Redefine Competition

NDH is just one part of a growing wave of data transparency efforts: price transparency, digital quality measures, and more. This administration has been prioritizing transparency with multiple executive orders and agencies have been issuing RFIs to set the stage for increased regulatory action.

Implications for payers:

  • You can no longer compete by hiding data about networks or patient access.
  • NDH, combined with AI-powered third-party consumer tools, will allow members and employers to make data-driven decisions about plans and networks. Innovation is occurring as brokers and their tech vendors seek to provide value-added services to employers and individuals.
  • Patient Access APIs will be able to pre-populate plan comparison and selection workflows, and streamline the ability for these decision support workflows to help match to the right plan.
  • Compete on value, quality, and experience—not opacity.
  • Take advantage of the public data sets for benchmarking and competitive analysis purposes.

Payers need to prepare for a future where AI agents will help members choose networks, evaluate quality, and optimize value-based care decisions. The government itself wants to leverage these APIs and machine-readable files to support research, compliance assessments, and to build their own decision support workflows for beneficiaries. They will be paying more attention to the accuracy and completeness of these data.

Recommendations:

  • Ensure that all mandatory public data sets are complete and accurate.
  • Be ready to review, respond, and act upon constructive feedback from regulators and third-parties.
  • Measure the consistency and alignment of the data ahead of time to anticipate and address the issues.

Final Thoughts

The National Directory of Healthcare represents a turning point in how provider data is managed, validated, and used across the healthcare ecosystem. For payers, it’s both an opportunity to streamline operations and a mandate to modernize data infrastructure and governance. Those who act early will not only be ready when CMS leverages the NDH to exercise greater scrutiny, but they will also be more ready to compete on value.