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How provider data works

How provider data works, from the NPI to the find-a-doctor page

A provider record passes through five layers before a member sees it. Each layer answers a different question and is run by different organizations. Here is what happens at each one, and where records go wrong.

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The five layers

A provider record passes through five layers before a member sees it

Each layer answers one question. The record moves down the stack, and an error in any layer shows up at the bottom, in front of a member.

  1. Who is this provider?

    Every U.S. provider who bills gets a National Provider Identifier from NPPES, run by CMS. The NPI never changes, so every other system keys its records to it. Providers enter and update their own NPPES details, and the data is published free.

    Who does it NPPES (CMS)
    Does Candor Health replace NPPES and CAQH?

  2. Is this provider qualified?

    Before a plan contracts with a provider, their licenses, training and history are checked against primary sources. Clinicians self-report once in CAQH and re-attest every 120 days. A credentials verification organization or credentialing software does the checking.

    Who does it CAQH Verisys symplr CertifyOS
    Does Candor Health do credentialing?

  3. Where do they practice today, and are they taking patients?

    Credentials say who a provider is, not where they are this month. Providers move, retire, change phone numbers and leave networks between attestations, and nothing in the first two layers notices until someone re-reports. This layer checks each record against outside evidence such as claims and keeps it current.

    Who does it Candor Health
    Is Candor Health a provider data management platform?

  4. Are there enough providers, close enough, for this plan?

    Regulators set time and distance standards for each provider type. Plans measure their network against them and file the results with CMS and state regulators. The count is only as good as the records being counted.

    Who does it Quest Analytics
    Does Candor Health measure network adequacy?

  5. How does a member find and book the right provider?

    Find-a-doctor portals, care navigation apps and scheduling tools turn the records into search results and booking links. When a record below is wrong, this is where the member finds out.

    Who does it Kyruus Health DexCare H1
    Is Candor Health a provider search or scheduling tool?

Where records go wrong

Most directory errors are records nobody updated

The first two layers depend on providers reporting their own changes. Between reports, the record drifts.

48.74%

Nearly half of listed locations had an error

In its Medicare Advantage provider directory review, CMS found at least one inaccuracy at 48.74% of the locations it checked: wrong address, wrong phone, or a provider not taking patients.

90 days

The law asks for verification every 90 days

The No Surprises Act requires plans to verify provider directory information at least every 90 days and to update it within two business days of a change.

120 days

Self-reported records lag behind real life

CAQH asks clinicians to re-attest every 120 days, and NPPES changes only when a provider files an update. A provider who moves or retires stays listed until then, which is how ghost networks form.

Questions people ask

Where Candor Health fits, in plain answers

Each answer has its own page, with the organizations that do that job and a source for every outside fact.

What changes

What customers measured after switching

50% less time per referral

Sana Benefits cut referral processing from about two hours to under one, and grew care navigation volume by more than 50% with no added headcount.

140,000 records removed

Sidecar Health removed inactive and retired providers that NPPES still listed, and reached 96.4% phone number accuracy across its directory.

4 states to 50

Sidecar Health scaled from 4 states to 50 while growing its provider footprint from 1.12M to 7.3M NPIs on Candor Health data.

FAQ

Questions about the data layer

Plain answers, including what Candor Health does not replace.

  • NPPES and CAQH are sources of provider data: NPPES is the federal NPI registry and CAQH holds provider-attested credentialing profiles. Both are valuable inputs, but each is self-reported and updated on the provider's schedule. Candor Health is a provider data management platform that ingests those sources alongside claims, state licensing boards and 120,000+ other sources, reconciles the conflicts between them and scores every field, so you get a single verified record rather than several partial ones.

  • Traditional directories rely on periodic manual attestation, so records drift out of date between cycles. Candor Health uses continuous AI-driven verification across 120,000+ sources and 4 billion+ monthly claims, scores every field for accuracy, and delivers the result through an API, flat-file feeds or a self-serve platform rather than a static directory.

  • No. Candor Health is the data layer underneath them. Your find-a-doctor portal, provider data management system, EHR and care navigation tools keep handling the display and the workflow; Candor Health feeds them continuously verified provider records through an API, flat files or the MCP server, with NPI, CCN and TIN already mapped. Most teams are live within weeks and nothing has to be ripped out.

  • Candor Health delivers data through APIs and bulk file exports designed to plug into directory platforms, EHRs, and care navigation tools. It works alongside your existing systems, so nothing has to be replaced.

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