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

State Regulation Health Plan Link to Official Content
Arkansas Must update directories every 14 days All Click here
California Must update online directories weekly All Click here
Colorado Must update directories monthly QHP Click here
Connecticut Must update directories annually MCO Click here
Delaware Must update online directories annually QHP Click here
Florida Must update online directories semi-annually EPO Click here
Georgia Must update online directories every 30 days MCO Click here
Idaho Must update directories monthly QHP Click here
Louisiana Must update directories annually All Click here
Maryland Must update online directories every 15 days All Click here
Montana Must update directories annually QHP Click here
Nevada Must update directories every 30 days QHP Click here
New Jersey Must update online directories every 10 days MCO Click here
New York Must update online directories every 15 days HMO Click here
North Carolina Must update directories annually All Click here
Oregon Must update online directories monthly MCO – Workers Comp Click here
Tennessee Must update directories annually MCO Click here
Texas Must update directories quarterly EPO, HMO, PPO Click here
Vermont Must update directories semi-annually MCO Click here
Washington Must update directories monthly All Click here (Subchapter B)
Wisconsin Must update directories annually HMO Click 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 Name Regulation Health Plans Link 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, Wyoming Must update provider directories monthly and collect up-to-date information from providers quarterly QHP & Medicare Medicaid Guidance 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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