Provider Data Management   /   July 2016

Provider Directory Regulations: A State-by-State Guide

Provider Directory Regulations: A State-by-State Guide

Provider directories have long been a source of inaccurate provider information. As a result, federal (CMS) and state regulations will be enforced to ensure that healthcare consumers receive accurate information. Failure to comply with these specific state regulations will result in certain penalties.

Stemming from work with health plans throughout the United States, our compliance team compiled a list of regulations for each state.

State Regulations

StateRegulationHealth PlanLink to Official Content
ArkansasMust update directories every 14 daysAllClick here
CaliforniaMust update online directories weeklyAllClick here
ColoradoMust update directories monthlyQHPClick here
ConnecticutMust update directories annuallyMCOClick here
DelawareMust update online directories annuallyQHPClick here
FloridaMust update online directories semi-annuallyEPOClick here
GeorgiaMust update online directories every 30 daysMCOClick here
IdahoMust update directories monthlyQHPClick here
LouisianaMust update directories annuallyAllClick here
MarylandMust update online directories every 15 daysAllClick here
MontanaMust update directories annuallyQHPClick here
NevadaMust update directories every 30 daysQHPClick here
New JerseyMust update online directories every 10 daysMCOClick here
New YorkMust update online directories every 15 daysHMOClick here
North CarolinaMust update directories annuallyAllClick here
OregonMust update online directories monthlyMCO – Workers CompClick here
TennesseeMust update directories annuallyMCOClick here
TexasMust update directories quarterlyEPO, HMO, PPOClick here
VermontMust update directories semi-annuallyMCOClick here
WashingtonMust update directories monthlyAllClick here (Subchapter B)
WisconsinMust update directories annuallyHMOClick here

 

Beyond the proposed timeline of updates, states have also released their expectations for provider directory content. If you would like to learn more about these specific requirements please contact us.

No State Regulation

Where there are no state requirements, the following CMS guidelines must be followed: Provider directories must contain relevant and accurate provider information. This will be implemented through directory maintenance through monthly updates of provider information and quarterly touch points with providers within a Qualified Health Plan network.

 

State NameRegulationHealth PlansLink to appropriate CMS letter
Alabama, Alaska, Arizona, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Mexico, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, Utah, Virginia, West Virginia, WyomingMust update provider directories monthly and collect up-to-date information from providers quarterlyQHP & Medicare MedicaidGuidance to Verify that Networks are Adequate and Provider Directories are Current (p. 134-135)

 

With the recent demand for transparency in healthcare, specifically in provider data, CMS federal regulations have been put in place to promote efficiency within the healthcare system. State regulations have begun to fall in line with this nationwide agenda. Thus, it is clear that no state is free of regulations pertaining to provider directories, and most states are aligning themselves with federal regulations.

Explanation of Acronyms
MCO – Managed Care Organization: Health plans that provide health care in return for a monthly fee and coordinate care through a defined network of physicians and hospitals. Examples of this include HMOs, PPOs and EPOs.
HMO – Health Maintenance Organization: Under this plan, enrollees have one primary care physician and need a referral before they can see any other healthcare professional, except in an emergency.
PPO – Preferred Provider Organization: Enrollees can go to any healthcare professional without a referral inside or outside a health plan’s network.
EPO – Exclusive Provider Organization: Enrollees have a limited network of doctors and hospitals to choose from, which is set by a health plan. It is important for enrollees to know who participates in their plan’s network
QHP – Qualified Health Plan: Designation given to health plans that are sold in the marketplace under the Affordable Care Act (ACA)

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