CAQH Provider Directory Snapshot FAQs for Providers and Practice Managers

Why is there a need to improve health plan provider directories?

The changing healthcare landscape brings new market realities: a wider range of consumer choices, lower-cost health plans with narrow provider networks, and limited knowledge among providers and patients about the specific insurance products in which they participate. Inaccuracies in provider directories can result in patients unknowingly accessing out-of-network providers or being unable to find where an in-network provider is located.

To address consumer concerns, the federal government, states and other regulatory bodies are issuing new regulations to ensure provider directories are current and accurate.

What is the provision summary for providers?

Medicare Advantage 2016 Call Letter

Beginning January 1, 2016, organizations with Medicare Advantage (MA) plans must maintain "regular, ongoing communications / contact with providers..."

To address the initial provider directory regulation requirements, MA plans must conduct outreach to providers at least quarterly to update and confirm their directory information. For providers, this means responding to all requests from their contracted MA plans. This can result in increased staff burden and administrative costs for providers and plans alike.

Additionally:

  • Requirements for Qualified Health Plans (QHPs) participating in the Federally Facilitated marketplace went into effect on November 1 of this year.
  • Twenty-six states have defined similar provider directory requirements for other health plan products.
  • The National Committee for Quality Assurance (NCQA) has included directory audit process rules for health plans accredited by that organization beginning July 1, 2016.”

No Surprises Act for Provider Directories 

Below is a snapshot of the requirements impacting providers.  For a comprehensive list, consult CMS.

Beginning January 1, 2022:

  • No balance billing for out-of-network emergency services (PHSA 2799B-1; 45 CFR 149.410)
  • No balance billing for non-emergency services by nonparticipating providers at certain participating health care facilities, unless notice   and consent was given in some circumstances (PHSA 2799B-2; 45 CFR 149.420)
  • Disclose patient protections against balance billing (PHSA 2799B-3; 45 CFR 149.430)
  • No balance billing for air ambulance services by nonparticipating air ambulance providers (PHSA 2799B-5; 45 CFR 149.440)
  • Provide good faith estimate in advance of scheduled services, or upon request (PHSA 2799B-6; 45 CFR 149.610 (for uninsured or self-     pay individuals)
  • Ensure continuity of care when a provider’s network status changes (PHSA 2799B-8)
  • Improve provider directories and reimburse enrollees for errors (PHSA 2799B-9)
  • Non-participating providers cannot bill or hold liable beneficiaries, enrollees or participants in group health plans or group or individual       health insurance coverage who received emergency services at a hospital or an independent freestanding emergency department for a   payment amount greater than the in-network cost-sharing requirement for such services.
  • A provider or facility must disclose to any participant, beneficiary, or enrollee in a group health plan or group or individual health     insurance coverage to whom the provider or facility furnishes items and services information regarding federal and state (if applicable)   balance billing protections and how to report violations.  Providers or facilities must post this information prominently at the location of the   facility, post it on a public website (if applicable) and provide it to the participant, beneficiary or enrollee in a timeframe and manner   outlined in regulation. 
Are there penalties for providers who don’t comply with the regulation?

Medicare Advantage 2016 Call Letter

Providers will not face monetary fines; however, patients may become frustrated if they cannot find their provider’s office location or learn after receiving services that the provider was not in-network. Maintaining accurate provider directory information can help improve patient service and satisfaction.

No Surprises Act for Provider Directories

Healthcare providers may face penalties of up to $10,000 for each violation.

Why did CAQH create an initiative to improve the accuracy of provider directory data?

The non-profit alliance, CAQH, has a legacy of building collaborative initiatives to solve industry-wide problems by engaging multiple health plans and healthcare providers. By committing to participate in this collaborative effort, health plans are helping to address the long-standing industry need for better quality provider data while reducing the administrative burden on providers.

For more than a decade, CAQH has been the leader in collecting and disseminating detailed, self-reported provider data to health plans and other healthcare organizations used for credentialing and other data needs through CAQH ProView. More than 1.9 million providers already use CAQH ProView to self-report and update their provider data. Working in concert with a number of health plans, CAQH is leveraging this rich provider dataset to help health plans and providers easily meet the new provider directory data confirmation requirements.

Why should I use CAQH ProView to maintain my provider directory information?

The new Provider Directory Snapshot within CAQH ProView, now makes it easy for providers to review, update and confirm their data needed for health plan provider directories. It will reduce the burden associated with redundant requests from different health plans.

Upon receiving an email reminder, providers simply log in to CAQH ProView and view their Provider Directory Snapshot within the regular CAQH ProView re-attestation process. After reviewing and updating any incorrect information, providers attest to its accuracy and confirm that it may be shared with the participating health plans with which they are contracted.  

To meet the Consolidated Appropriations Act, 2021 - NSA providers will receive an email from the CAQH ProView team quarterly asking ​​​​​providers to confirm practice-related information. The communication serves as a reminder to assist all parties in meeting their obligations under the Act and will help improve the accuracy of directories that patients rely on to find a provider.

The CAQH ProView team simplified the process of updating your practice location data with several convenient methods.

Providers can update and confirm locations by:

  • Verifying a locations information does not require changes;
  • Updating information within a location; or 
  • Archiving, rejecting or, restoring a previously archived location (only if the location is not missing any required fields).

Lastly, providers may confirm all their self-managed locations by attesting to their profile.

Provider practice location screens display a date stamp of the last time the information was confirmed. 

If the providers practice location record has not been reviewed or updated in 60 days, the provider will be alerted to indicate if the information is accurate. The confirmation date will be updated after selecting the ‘No Change’ button.​

Which health plans are participating in the CAQH Provider Data Confirmation Initiative? 

A list of participating plans is available here.  In order to make it easier for you to update your provider directory information all in one place, we invite you to contact non-participating health plans and encourage them to join this collaborative effort.  As new health plans join, they will be listed on the CAQH website here.

How do I update my directory information in CAQH ProView?
  • Log in to CAQH ProView by entering your username and password. 
  • On the Attestation page, follow these three steps:
    1. Click the link to view your Provider Directory Snapshot. If any data is incorrect, click X (in the upper right-hand corner) to close the snapshot and make changes within your CAQH ProView profile.
    2. Click Verify Review once you have made updates or if no changes are needed.
    3. Indicate that you have reviewed your Provider Directory Snapshot and then click Attest.
  • The Attestation Completed screen will appear and you will receive a confirmation email. 

If you need more information on how to update your provider directory information within CAQH ProView, please review the detailed Provider Directory Data Confirmation Initiative Reference Guide.

When I confirm my directory information do I need to complete an attestation to my full data profile?

Yes. The process of updating and confirming your provider directory information is part of the regular CAQH ProView re-attestation process.  The system will prompt you to make any other updates to your full data profile, making your attestation complete.

Does this affect the timing for my regular CAQH ProView attestation?

Due to regulatory requirements about the frequency of outreach to healthcare providers, CAQH will contact you quarterly (every 90 days) to complete this process for provider directory updates.

Providers who complete the required steps upon receipt of the quarterly email will no longer receive notices to re-attest to their CAQH ProView data profile every 120 days. You will now be able to perform two important functions concurrently – updating health plan directory information and re-attesting to all your CAQH ProView professional information – saving time and reducing administrative burden. 

What directory-related notifications will CAQH send to me?

Based on the new requirements, health plans must contact you on a regular basis to confirm updates to your directory information.  CAQH will combine requests from all participating health plans into a single directory reminder email sent quarterly (every 90 days); the frequency may change in the future if new regulations require it.

These notifications will be sent to your primary method of contact email address listed in CAQH ProView.  If you have a designated contact, such as a credentialing specialist or practice manager, listed as your primary email, please make them aware of the importance of maintaining provider directory data updates within CAQH ProView. 

I recently re-attested to my full data profile in CAQH ProView.  Do I need to do anything further to confirm my directory information?

Yes. If one or more of your contracted health plans has placed you on their provider directory roster (i.e., requested that you update your provider directory profile within CAQH ProView) and CAQH has emailed you that request, you should log in to CAQH ProView to review your Provider Directory Snapshot.  Then, make any needed updates to that information within CAQH ProView and confirm its accuracy during Step 3 of the Attestation process. 

I practice at multiple locations, and not all of these locations should be published in a directory.  Does the Provider Directory Snapshot enable me to indicate which specific practice locations can be published?

No. The system does not enable you to select specific locations for publication. 

What if I am not currently registered with or using CAQH ProView?

If you are not currently registered with CAQH ProView and have received an introductory email welcoming you, please click on the link provided in the email to get started. You may also go directly to https://proview.caqh.org and click on “Register Now” to start the process.

When can I start using CAQH ProView to update and confirm my directory information?

Once a participating health plan has submitted your name on their provider directory roster, you will receive an email request to login to CAQH ProView to review your Provider Directory Snapshot.  You can then update your directory information within CAQH ProView, and confirm its accuracy using the “Attest” screen.  NOTE:  Only providers who have been asked by a health plan to participate in this new process will be able to see their Provider Directory Snapshot.  

If you are not currently using CAQH ProView to maintain your full provider data profile, you are encouraged to do so by visiting https://proview.caqh.org and click on “Register Now” to start the process.

Is there a charge to use CAQH ProView to update my provider directory information?

No.  The process for providers to update their health plan directory information is within CAQH ProView, so there is no charge to providers.

How can I learn more?

If you need more information on how to update your provider directory information within CAQH ProView, please review the detailed Provider Directory Data Confirmation Initiative Reference Guide​.

For more information on CAQH ProView, click here.

You may also contact the CAQH ProView Support Center at 888-599-1771 for any questions related to CAQH ProView or with maintaining your provider directory information.

 

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