Section 4540.60 Provider Directory Audits

Section 4540.60  Provider

Directory Audits

a)         By April 1 of each year, an insurer shall file with the

Department a report applicable to all provider directories of all its network

plans that describes the protocols the insurer uses to ensure that it complies

with the requirements in Section 25 of the Act to keep each electronic

directory up-to-date, accurate, and complete by updating it both at least

monthly and within 10 business days of receipt of updated information from

preferred providers, as well as to update the print directory and errata quarterly

and to ensure that the print directory is accurate as of the date of

publication.  The report shall also describe the insurer’s current verification

process established pursuant to 42 U.S.C. 300gg-115(a)(2).  The report shall

also describe any changes to these protocols and to the verification process

that have occurred since the beginning of the previous calendar year. The

report shall describe all variances in the protocols and the verification

process among the insurer’s network plans or between its different provider

directories, including any distinctions made among HMO and Preferred Provider

Organization (PPO) networks.  An insurer that demonstrates that, at all times

during the audit period, the contents of any print directory are printed from

the same data used for the corresponding online directory on the same date of

printing is exempt from auditing the print directories separately.  For 2023,

the report shall be filed no later than July 1.

b)         An insurer must conduct the periodic self-audit required

under Section 25(a)(3) of the Act for each provider directory no less than

twice per year.  If an insurer has not completed a self-audit for each provider

directory by the date this rule takes effect, it shall audit the provider

directory for that network plan and generate a report by July 1, 2023

e filed no later than July 1.

b)         An insurer must conduct the periodic self-audit required

under Section 25(a)(3) of the Act for each provider directory no less than

twice per year.  If an insurer has not completed a self-audit for each provider

directory by the date this rule takes effect, it shall audit the provider

directory for that network plan and generate a report by July 1, 2023.  The

insurer’s unredacted internal self-audit reports generated during the previous

calendar year shall be attached to the report required under subsection (a).

c)         Each self-audit report generated on or after July 1, 2023 must

include a summary specifically identifying each print and electronic directory

audited, the marketing name of each network plan using that directory, and the

SERFF Tracking Number of the most current filing under Section 10 of the Act that

contained the directory. The summary must specify, at a minimum:

1)         For each print or electronic directory audited and each

provider specialty type in that directory, the number of preferred providers

for which the self-audit revealed any incorrect provider directory information

at the time of audit;

2)         For each print or electronic directory audited and for

each provider specialty type in that directory, the number of preferred

providers that had furnished corrected or updated information to the insurer more

than the following number of business days prior but the self-audit revealed

any incorrect provider directory information still present:

A)        for an electronic directory, 10 business days before the

auditor reviewed that provider’s directory information, and

B)        for a print directory that is not an on-demand, unaltered

printout of the electronic directory, 10 business days before the date of

printing;

3)         For each print or electronic directory audited and for

each provider specialty type in that directory, the number of:

A)        preferred providers with directory entries updated since

the prior s

rovider’s directory information, and

B)        for a print directory that is not an on-demand, unaltered

printout of the electronic directory, 10 business days before the date of

printing;

3)         For each print or electronic directory audited and for

each provider specialty type in that directory, the number of:

A)        preferred providers with directory entries updated since

the prior self-audit;

B)        preferred providers that submitted updates to their

provider directory information since the prior self-audit; and

C)        preferred providers from whom the insurer requested updated

information because of the self-audit or other internal detection of inaccurate

information or any complaint received of inaccurate provider information since

the prior self-audit;

4)         For each print or electronic directory audited and for

each provider specialty type in that directory, the smallest, largest, and

median number of business days since the prior self-audit between:

A)        the insurer’s receipt of updated information from a

preferred provider or the termination of a provider contract if the insurer is

contractually required to update the directory on its own initiative; and

B)        the insurer’s update to the electronic or print provider

directory;

5)         The combined totals of the numbers in subsections (c)(1)

through (4) across all provider specialty types, both within each directory and

across all directories provided by the insurer; and

6)         A high-level evaluation of the effect of known internal or

external processes or circumstances and changes to those processes or

circumstances on the accuracy of the insurer’s directories and the timeliness

of updates to directory information under State and federal requirements.

d)         Any time the insurer submits a report or other

documentation to the federal Centers for Medicare and Medicaid Services related

to the insurer’s compliance with 42 U.S.C

nal processes or circumstances and changes to those processes or

circumstances on the accuracy of the insurer’s directories and the timeliness

of updates to directory information under State and federal requirements.

d)         Any time the insurer submits a report or other

documentation to the federal Centers for Medicare and Medicaid Services related

to the insurer’s compliance with 42 U.S.C. 300gg-115(a)(2), the insurer shall give

the Department a copy of that report or documentation.

e)         The Director may request additional information upon receipt

of a self-audit report and may at any other time audit the accuracy of any

network plan's provider directory.

f)         Reports

required under this Section shall be filed in SERFF as a network adequacy

filing separately from the insurer’s filings required under Section 10 of the

Act.