W. Va. Code R. § 114-100-7

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-100-7 - Provider Directories

7.1. Provider directories shall be maintained by a health carrier for each of its health benefit plans having a network plan. Sample screen shots of the carrier's electronic provider directory and a PDF sample of the carriers printed provider directory must both be filed in SERFF with the access plan filing.

7.2. Provider directories maintained by a health carrier shall meet all of the following requirements:

7.2.1. A health carrier shall post electronically a current and accurate provider directory for each of its network plans with the information and search functions as described in W.Va. Code § 33-55-4;

7.2.2. When making the directory available electronically, the health carrier shall ensure that the general public is able to view all of the current providers for a network through a clearly identifiable link or tab without requiring an individual to create or access an account or requiring the entry of a policy or contract number;

7.2.3. The health carrier shall include a disclosure in the directory of the date of the most recent update for electronic directories, or the date of printing for printed directories. This disclosure shall state that the information included in the directory is accurate, to the best of the carrier's knowledge, as of the date of updating/printing, and that covered persons or prospective covered persons should consult the carrier's electronic provider directory on its website, or call the carrier's customer service telephone number, to obtain current provider directory information;

7.2.4. A health carrier shall provide a print copy of the requested pertinent portion of the current provider directory to a covered person or a prospective covered person within five business days of the request;

7.2.5. A health carrier shall include, in both the electronic and print directory, the following general information for each of its provider networks:

7.2.5.a. A description of the criteria the health carrier has used to build its provider network;

7.2.5.b. A note that an authorization or referral may be required to access some providers;

7.2.5.c. A description of the criteria the health carrier has used to tier providers; and

7.2.5.d. A description of how the health carrier designates the different provider tiers or levels in the network and identifies (e.g., by name, symbols or grouping) which tier or level the following are placed in:

7.2.5.d.1. Each specific provider;

7.2.5.d.2. Each specific hospital; and

7.2.5.d.3. Each specific other type of facility in the network;

7.2.6. A health carrier shall make it clear, in both its electronic and print directories, which provider directory applies to a particular health benefit plan, such as including the specific name of the health benefit plan as marketed and issued in West Virginia;

7.2.7. The health carrier shall include, in both its electronic and print directories, customer service contact information by electronic means such as email, text, social media, telephone number, and an electronic link that covered persons or the general public may use to notify the carrier of inaccurate provider directory information;

7.2.8. For the items of information required in a provider directory pursuant to W.Va. Code § 33-55-4 pertaining to a health care professional, a hospital, or a facility other than a hospital, the health carrier shall make available, through the directory, the source of the information and any limitations; and

7.2.9. A provider directory, whether in electronic or print format, shall accommodate the communication needs of individuals with disabilities, and include a link to or information regarding available assistance for persons with limited English proficiency.

7.3. A health carrier shall update each electronic provider directory at least monthly. Current provider directories shall be made available to the Commissioner, upon request.

7.4. No less frequently than three times during each plan year, a health carrier shall audit at least 50% of the providers contained in its provider directories for accuracy and update that directory based upon its findings. Every provider in the directory must be audited at least once during each plan year.

7.5. Audits shall be conducted such that all entries in a provider directory will be audited at least once every eighteen months. Documentation of the process and findings of all audits and the information required by this rule shall be retained for no less than 36 months and shall be made available to the Commissioner upon request.

W. Va. Code R. § 114-100-7