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 are the new provider directory regulations?
Regulatory and accrediting bodies are imposing new provider directory requirements on health plans. They include:
- No Surprises Act for Provider Directories: Beginning January 1, 2022, these No Surprises Act requirements will apply to items and services provided to most individuals enrolled in private or commercial health coverage. Providers and insurers must maintain business processes to submit provider directory information at specified times to support plans and issuers in maintaining accurate, up to date provider directories.
- Medicare Advantage 2016 Call Letter: Beginning January 1, 2016, organizations with Medicare Advantage (MA) plans must maintain “Regular, ongoing communications / contacts with providers...”
- CMS Memo to Medicare Advantage Plans: Clarifies that plan contact with providers must occur at least quarterly.
- HHS Notice of Benefit and Payment 2016: As of November 2015, Qualified Health Plan (QHP) issuers must update their provider directory information at least once a month.
- Includes field-level requirements for data.
- Medicaid and CHIP Proposed Rule: Medicaid MCOs must update electronic provider directories no later than three business days after data is received from the provider.
- 2016 HPA Network Management Standard: Using valid sampling methods, health plans must analyze the accuracy of information within provider directories.
In addition, 26 states now have similar provider directory requirements for other health plan products.
What happens if a health plan doesn’t comply with the regulation?
Health plans may face monetary fines for noncompliance.
How does DirectAssure work?
The one-to-many solution enables providers to update a specific subset of their information required for provider directories within CAQH ProView. That information can then be shared with all participating health plans which providers authorize to receive their information. This process eliminates the need for outreach to providers from every plan with which they contract.
Beginning in December 2015, CAQH started emailing quarterly reminders to healthcare providers on behalf of participating health plans to review their directory information. The email asks providers to log in to CAQH ProView, review their provider directory information (“Provider Directory Snapshot”), make any necessary updates and then confirm that this information can be published. Those who do not respond to email are also contacted by phone. The confirmation is time stamped, and a snapshot of the information is taken for audit purposes.
Directory confirmation integrates with the regular CAQH ProView attestation process that providers are familiar with for credentialing purposes, making the experience seamless.
What data elements will providers be asked to review for DirectAssure?
Providers are asked to review, update and confirm a directory-specific subset of their full CAQH ProView data profile – the “Provider Directory Snapshot” – as part of the usual attestation process. The included fields are based on federal and state regulatory requirements and feedback from CAQH member plans. Additional data elements may be added in the future based on the needs of participating health plans.
The following data elements are currently included in each Provider Directory Snapshot:
- NPI Type 1
- Non-English Languages Spoken
- Participate in Medicare
- Participate in Medicaid
- Professional School and Degree
- Undergraduate School and Degree
- Specialty and Board Certification
- Practice Location Information
- Group Name
- NPI Type 2
- Office Hours
- Accepting new patients
- ADA and Handicap Accessible
- Hospital Affiliation – Hospital Name and Address
Is DirectAssure easy for providers to use?
Yes. Providers who are already familiar with CAQH ProView will find the solution easy to use. Revising outdated data is quick. In fact, CAQH conducted a pilot to test the solution with 3,000 providers, and their feedback was overwhelmingly positive.
How does the solution notify providers to update and confirm their directory information?
Based on the new requirements, health plans must contact providers regularly to confirm and update their directory information. DirectAssure consolidates these requests for directory updates from multiple health plans into a single quarterly reminder email to providers.
All providers on a health plan provider directory roster receive this reminder email to log in to CAQH ProView to review, update and confirm their directory information. These email notifications are sent to the “primary method of contact” email address in CAQH ProView listed for each provider.
How often does CAQH conduct outreach to a provider to confirm directory information?
CAQH emails all providers on a health plan's CAQH directory roster on a quarterly basis. The email asks them to review, update and confirm their directory information shown in their “Provider Directory Snapshot.”
Does CAQH conduct outreach to providers in Expired status?
Yes. CAQH conducts outreach to all providers, regardless of their CAQH ProView status. If a provider in Expired status does not respond to the email outreach, CAQH will initiate a phone call to the provider. Phone calls are prioritized for providers who have been expired the longest, with a target of at least one phone outreach every six months to providers who do not respond to email communications.
Will DirectAssure change the standard attestation cycle used in CAQH ProView?
Directory confirmation integrates with the regular CAQH ProView attestation process. Providers are now able to both update their health plan directory information and re-attest to all their CAQH ProView professional information concurrently. Providers who complete the required attestation steps upon receipt of the quarterly email will, in fact, be re-attesting to their data every 90 days.
However, should providers not follow this 90-day schedule to update their provider data, they are still required to attest to their data profiles every 120 days (every 180 days for IL providers) to comply with credentialing requirements. If providers do not attest within the required timeframe, their CAQH ProView status will be changed to Expired.
What documentation is available to provide a record of the provider outreach?
Participating health plans have access to the Outreach Compliance Report, an auditable record of provider outreach performed by CAQH. CAQH reports on all active providers on a participating health plan’s directory roster who have completed attestation in CAQH ProView, a record of all provider-facing communications, and the outcomes of those communications. This report is provided in ASCII or Excel format and available on the sFTP server.
The report includes:
- Provider Identifiers (Name, CAQH Provider ID, Type 1 NPI)
- Directory Confirmation Date
- Recipient Email Address
- Email Timestamp
- Phone Number Called
- Phone Call Timestamp
- Phone Call Outcome
If a provider updates directory-specific information, is this data also available in the CAQH ProView standard extract used for credentialing and other purposes?
Yes. All attested provider updates made for directory use are available in the CAQH ProView standard extract. Each provider’s data profile remains as a single dataset within CAQH ProView. This increases the accuracy of provider data used for credentialing and other purposes.
Does DirectAssure require a different roster than CAQH ProView?
Yes. Health plans need to submit and maintain separate roster files for provider directory and all other uses, including credentialing. The provider directory file requires a specific format. Please contact your CAQH account manager to obtain access to the roster file specifications.
Providers submitted on a provider directory roster do not need to have an existing CAQH ProView account or already be included on a traditional CAQH ProView roster. CAQH sends new providers a welcome email inviting them to join CAQH ProView to create, update and maintain their directory information.
How often may a roster file be submitted?
Roster additions may be submitted daily. Rosters should reflect the names of providers currently participating in, or contracted with, the health plan’s network.
Does a health plan need to submit the full roster file every time or just updates?
Health plans should send only additions and deletions after the initial directory roster submission. Providers remain on a plan’s directory roster until the plan explicitly indicates they should be removed.
For credentialing, I was able to add and remove providers from my roster via the CAQH ProView web interface. May I continue to do that for DirectAssure?
As of January 2016, adding and removing providers within the roster is managed via SFTP roster files.
What if I would like the traditional CAQH ProView and directory rosters to have the same set of providers? Do I still need to submit two different files with the same providers?
Yes, the system has been designed for different sets of providers, to allow for cases in which a plan must outreach to providers whom they are not credentialing.
CAQH can assist in transforming a current return roster into directory roster. After the initial directory roster submission, you will have to submit the same additions and removals to both rosters.
Do participating health plans receive a provider directory return roster and extract separate from current CAQH ProView files?
Yes. A provider directory return roster is sent to organizations participating in DirectAssure.
A provider directory extract is available to health plans that participate in DirectAssure. This data extract contains any confirmed and attested information for all providers on an organization’s provider directory roster. Data extracts include only those providers who have attested since the last extract was received. A summary file is included in the extract to identify what directory information has changed since the last attestation.
How is CAQH communicating DirectAssure to providers and practice managers?
CAQH emailed all practice managers currently using CAQH ProView to inform them about reviewing, updating and confirming a directory-specific subset of the full CAQH ProView data profile – the “Provider Directory Snapshot”. The CAQH ProView training webinars are augmented with information related to how to update and confirm provider directory information. Training documentation and FAQs are also available to providers and practice managers. Click here for FAQs to distribute to your provider network.