Sara Jasper, JD
Staff Attorney
The Therapist
July/August 2017

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Since July 1, 2016, health plans and health insurers have been required to publish and maintain online and printed provider directories with information about contracting providers who offer services to enrollees or insureds.¹

This law is the result of widespread recognition that provider directories are often inaccurate, misleading and unhelpful to consumers who are attempting to access care. The goal of California’s provider directory law is to ensure consumers have access to a highly accurate list of available providers through searchable online directories and printed directories. Eventually, the goal is to be able to take the information from the plan and insurer-driven directories to create a multi-plan/ multi-insurer directory that is accessible to consumers through the California Department of Managed Health Care’s (DMHC) and the California Department of Insurance’s (DOI) websites. In addition, Medicare, Medicaid, state governments and health coverage exchanges are passing legislation and regulations to address these issues.

Minimum Provider Directory Standards
In accordance with the law, the DMHC and the DOI developed minimum provider directory standards² which all provider directories must follow as of January 1, 2018. The standards require directories to include the following:³

• Information about in-network providers such as the information indicated below⁴
• An individual provider’s panel status as either accepting new patient, accepting existing patients, available by referral only, available only through a hospital or facility, or not accepting new patients
• Providers’ National Provider Identifier (NPI) numbers (if available)
• Practice addresses and locations consistent with United States Postal Service conventions⁵
• If a network includes network tiers, identify the tier level associated with each provider and an explanation of the differences between each network tier
• With the written permission of the provider, display a provider’s office email address
• Any alternative names preferred by the provider

The standards also encourage health plans and insurers to include links to provider websites and statements describing whether the provider’s office/facility has accommodations for persons with physical disabilities.

Accuracy of Directory Information
In order to ensure the accuracy of the information contained in these directories, the law requires health plans and insurers to do the following:

• At least annually review and update the entire provider directory or directories for each product offered⁶
• Update online provider directories on a weekly basis⁷ when a contracting provider is no longer accepting new patients; when a contracting provider is no longer under contract; when a provider’s practice location has changed; when a change in necessary based on an complaint that the provider was no longer accepting new patients, was not available or whose contact information was listed incorrectly⁸

• Update printed provider directories on a quarterly basis^{9 10}

Plans’ and Insurers’ Additional Responsibilities to Consumers
In addition to the minimum directory standards developed by the DMHC and the DOI, plans and insurers must take the following measures to facilitate consumers’ use and access to providers’ directory information:

• Online provider directories must be searchable by name, practice address, city, ZIP code, California license number, National Provider Identifier (NPI) number, admitting privileges to an identified hospital, product, tier, provider language or languages, provider group, hospital name, facility name, or clinic name¹¹
• Online provider directories must be made available to the public without any restrictions or limitations such as requiring the use of a login or requiring members of the public to first indicate interest in obtaining coverage with the plan¹²
• Delete a provider from a directory or directories when a provider has retired or discontinued his or her practice or when a provider is no longer under contract¹³
• Explain the right of enrollees and insureds to access language interpreter services at no cost and state that enrollees with disabilities have full and equal access to covered services¹⁴
• Develop a process for verifying providers’ information
• Promptly display a telephone number, email address and hyperlink to enable consumers to report inaccurate, incomplete or misleading information contained in the directories^{15 16}
• When consumer complaints regarding inaccurate provider information are received, investigate within 30 business days and either verify the information or update the provider directory or directories¹⁷
• Within the directory or directories, inform enrollees and insureds may submit a complaint if an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information¹⁸
• Reimburse for any amount beyond what the enrollees or insureds would have paid for in-network services when either the DMHC or DOI determines those enrollees and insureds reasonably relied on provider directories to make decisions about their health care providers

Plans’ and Insurers’ Responsibilities to In-Network Providers
Every six months, or annually—depending on providers’ status as an individual or group— plans and insurers are required to notify providers of the following:¹⁹

• The information the plan or insurer has in its directory or directories about the provider, including a list of networks and plan products that include the contracted provider or provider group
• A statement that failure to respond to the notification may result in a delay of payment or reimbursement of claims²⁰
• Instructions on how the provider or provider group can update the information in the provider directory or directories on the plans’ or insurers’ websites/provider portals²¹
• Receipt of a consumer complaint that the provider’s directory information is inaccurate, incomplete or misleading within 5 business days²²
• Any intent to remove providers or provider groups from their directories 10 business days ahead of the scheduled removal date^{23 24}

Provider Responsibilities
California’s directory laws also require providers to work with the plans and insurers they are contracted with to supply the following data:²⁵ 

• Name
• Practice location(s)
• Contact information
• Practitioner type
• National Provider Identifier
• California license number and type of license
• Area of specialty, including board certification(s)
• Office email address, if available
• Provider group affiliations
• Non-English languages spoken
• Whether accepting new patients
• Network tier

Under California’s directory laws, providers and provider groups are also required to confirm the accuracy of the information contained in plans’ and insurers’ directory or directories.²⁶ Providers must report to plans within 5 business days any change in their panel status.

If a provider who is not accepting new patients is contacted by an enrollee, or potential enrollee, the provider must direct the consumer to the plan for additional assistance with locating a provider and direct the enrollee to the DMHC to report any inaccuracy within the provider directory. Providers are required to verify or submit changes to the directory information using whatever processes are indicated by the health plans or health insurers. Providers must participate and affirmatively respond to a plan’s biannual or annual provider verification process. When providers fail to respond to the plans’ or insurers’ attempts to verify their information, plans and insurers may delay payments or reimbursements owed to the providers.²⁷ Plans and insurers may also terminate providers’ contracts for failure to inform of changes in directory information.²⁸

Conclusion
Providers and provider groups who are contracted with plans and insurers to offer behavioral health services must be aware of, and responsive to, plans and insurers attempts to verify their information in accordance with California’s provider directory laws. While providers may feel these directory requirements are a burden, the State’s goal is to ensure that consumers of behavioral health services are able to access treatment in a timely manner. Members who are having difficulty notifying plans or feel the notifications processes are problematic, should feel free to call CAMFT’s Legal Department to discuss.

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Sara Jasper, JD, is a staff attorney for CAMFT. Sara is available to answer member calls regarding legal, ethical, and licensure issues.

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Endnotes

¹ Cal. Health & Safety Code §1367.27 & Cal. Insurance Code §10133.15
² Cal. Health & Safety Code §1367.27(k)
³ While the DMHC and DOI have set forth the minimum standards for provider directories, health plans or insurers may implement additional directory features that exceed the minimum standards.
⁴ These provider directories are prohibited from listing or including information about providers who are not currently under contract (Cal. Health & Safety Code §1367.27(a))
⁵ Directories should clearly note cases where health care services are provided only in a patient’s home or through telehealth services.
⁶ Cal. Health & Safety Code §1367.27(l)
⁷ Cal. Health & Safety Code §1367.27(e)(1)
⁸ Cal. Health & Safety Code §1367.27(e)(1)(A-E)
⁹ Cal. Health & Safety Code §1367.27(d)(2)
¹⁰ Members of the public may request a printed copy of the provider directory or directories by contacting the plan through the plan’s toll-free telephone number, electronically or in writing (Cal. Health & Safety Code §1367.27(d)(1)
¹¹ Cal. Health & Safety Code §1367.27(c)(2)
¹² Cal. Health & Safety Code §1367.27 (c)(1)
¹³ Cal. Health & Safety Code §1367.27(e)(2)(A-B)
¹⁴ Cal. Health & Safety Code §1367.27(g)
¹⁵ Cal. Health & Safety Code §1367.27(f)
¹⁶ Plans and insurers are required to promptly investigate these complaints and take corrective action within 30 business days (Cal. Health & Safety Code §1367.27(j)(3)
¹⁷ Cal. Health & Safety Code §1367.27(o)(1)
¹⁸ The DMHC or the DOI may require the pans or insureds to reimburse for any amount beyond what the enrollees or insureds would have paid for in-network services when those enrollees and insureds are found to have reasonably relied on the provider directories to make decisions about their health care providers (Cal. Health & Safety Code §1367.27(q)
¹⁹ Individual providers not affiliated with a provider group must be notified at least once every six months (Cal. Health & Safety Code §1367.27(l)(1)(A)). All other providers must be notified annually (Cal. Health & Safety Code §1367.27(l)(1)(B)
²⁰ Cal. Health & Safety Code §1367.27 (l)(2)(B)
²¹ Cal. Health & Safety Code §1367.27(l)(2)(C)
²² Cal. Health & Safety Code §1367.27(o)(2)(A)
²³ Cal. Health & Safety Code §1367.27(p)(4)
²⁴ A provider cannot be removed from a directory or directories if he or she responds to the notice before the end of the 10-day notice period (Cal. Health & Safety Code §1367.27(l)(4)
²⁵ Cal. Health & Safety Code §1367.27(h)(1-8)
²⁶ Cal. Health & Safety Code §1367.27(l)(3)
²⁷ Plans may not delay payment unless it has attempted to verify provider information and must notify the provider 10 business days prior to seeking to delay payment or reimbursement (Cal. Health & Safety Code §1367.27(p)(1)(A-B); Cal. Health & Safety Code §1367.27 (p)(2))
²⁸ Cal. Health & Safety Code §1367.27(p)(3)

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This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.

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