D.C. Mun. Regs. tit. 26, r. 26-A4705

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 26-A4705 - PROVIDER DIRECTORIES

4705.1

A health carrier shall post electronically a current and accurate provider directory for each of its network plans. The directory should include at least the following information:

(a) The following identifiers for health care professionals:

(1) Name;

(2) Gender;

(3) Participating office location(s), ADA accessibility and contact information;

(4) Specialty;

(5) Facility affiliations;

(6) Languages spoken other than English; and

(7) Whether accepting new patients;

(b) The following identifiers for hospitals:

(1) Hospital name;

(2) Hospital type (i.e., acute, rehabilitation, children's, cancer); and

(3) Participating hospital location, and contact information; and

(c) The following identifiers for facilities, other than hospitals, organized by type:

(1) Facility name;

(2) Facility type; and

(3) Participating facility location(s), ADA accessibility and contact information.

4705.2

The directory for individual and small group plans shall be made available to the District of Columbia Health Benefit Exchange Authority ("Exchange"), provided at regular intervals, and in a format approved by the Commissioner for use to populate the Exchange's single provider directory search tool.

4705.3

The directory available electronically for a plan on a carrier's own website shall allow the general public to view all of the current providers, except for those providers which a carrier may need to suppress, through a clearly identifiable link or tab without creating or accessing an account or entering a policy or contract number.

4705.4

Carriers shall make the directory available by mail, to covered persons or potential covered persons in hard copy upon request. The hard copy may be a print-out of all or part of the online directory sufficient to meet the needs of the requester and not a pre-printed book.

4705.5

To ensure online directory accuracy, the health carrier shall do the following:

(a) Include in its directories a customer service email address or electronic link, and telephone number, that covered persons and the general public may use to notify the carrier of inaccurate information;

(b) Maintain a log, looking back at least two years of provider directory inaccuracies reported to the carrier, and make the log available to the Commissioner upon request;

(c) Validate reports that online directories are inaccurate or incomplete, and correct flawed provider information within thirty (30) days;

(d) On a quarterly basis, for providers who have not filed a claim with a carrier in two years or more, verify, audit, and update (if necessary).

(e) Conduct, at a minimum, an annual audit of at least fifteen percent (15%) of providers in each specialty included in § 4702.5 and § 4702.6 in each of its networks, to determine whether their network status and contact information in the carrier's directory are accurate or require updates. Necessary updates shall be completed within one month of the completion of an audit; and

(f) Make it clear which products its provider directory applies to.

4705.6

A carrier who uses Council for Affordable Quality Healthcare's DirectAssure, or other similar resource approved by the Commissioner, will be deemed compliant with § 4705.5 upon submission of supporting documentation from the health carrier.

4705.7

Where a covered person receives covered services from a non-participating provider, where the online directory indicates that the provider is a participating provider at the time the services are rendered, the carrier shall reimburse the provider for the full amount of services billed, less the amount of cost-sharing as if the services were obtained from a participating provider, and the cost-sharing shall apply to the in-network deductible and out-of-pocket maximum.

4705.8

Covered persons who believe they are entitled to in-network benefits due to material error in an online directory may appeal a denial of such benefits through internal and external appeals processes.

4705.9

Both electronic and print provider directories shall include in plain language that authorization or referral may be required to access some providers and the process to obtain that authorization or referral.

4705.10

Both electronic and print provider directories shall accommodate the communication needs of individuals with disabilities and include a link to or information regarding assistance for persons with limited English proficiency.

4705.11

A printed directory shall include a disclosure that the information provided is only accurate as of the date printed, and that a more current provider directory after that date may be available and obtained at a specific electronic link, or a customer service telephone number.

4705.12

When a covered individual requests information regarding a provider directory:

(a) A carrier shall respond as soon as practicable and in no case later than 1 business day after the request for information is received; and

(b) A carrier shall retain such communication in such individual's file for at least two (2) years following such response.

D.C. Mun. Regs. tit. 26, r. 26-A4705

Final Rulemaking published at 70 DCR 2231 (2/17/2023)