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What are the Transparency Requirements for Provider Directories?

EBIA  

EBIA  

QUESTION: We’ve heard that our group health plan’s provider directories will be subject to specific transparency requirements. What are they, and when do they apply?

ANSWER: For plan years beginning in 2022, a group health plan is required to establish a database on its public website that contains a list with directory information for each health care provider and facility with which it has a direct or indirect contractual relationship for furnishing items and services. Required information includes the provider’s name, address, specialty, telephone number, and digital contact information. If the group health plan maintains a print provider directory in addition to the database, it must include a notification in the print directory that the printed information was accurate as of the date of publication and that enrollees should consult the plan’s public website database or contact the plan for the most current provider directory information.

In addition, a plan must establish a process to verify and update, at least once every 90 days, the information included in the website database. The process must include a procedure for removing a provider or facility from the database if the plan has been unable to verify the directory information during a period specified by the plan and must also provide for updating the database within two business days after the plan receives new provider or facility information. Furthermore, the plan must establish a protocol under which it responds to a request by an individual enrolled in the plan about whether a provider or facility has a contractual relationship to furnish items or services under the plan. (See our future Question of the Week on the required protocols for responding to requests.)

Although these transparency requirements for provider directories apply to plan years beginning on or after January 1, 2022, the agencies have advised that they will not issue rules until after the effective date. In the meantime, plans are expected to implement these provisions using a good faith, reasonable interpretation of the statute. For more information, see EBIA’s Health Care Reform manual at Section XXXVII.E.4 (“Provider Directory Disclosures”). See also EBIA’s Self-Insured Health Plans manual at Section XXVIII.I (“Surprise Medical Billing Transparency Disclosures”).

Contributing Editors: EBIA Staff.

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