Background
- Since 2022, the federal No Surprises Act has required all private health plans to maintain accurate provider directories and verify and update provider directory information at least every 90 days.
- Massachusetts regulation has long required that health plans establish appropriate systems for maintaining accurate provider directories. However, there were significant gaps in what was collected and displayed, resulting in the enactment of Chapter
124 of the Acts of 2019, with requirements for improving health plan provider directories so that consumers can easily locate participating providers.
- In November 2023, the Division of Insurance (DOI) finalized the regulation relating to Chapter 124 that expands the requirements that health plans have to follow for collecting, storing, displaying and auditing provider directory information.
Health plans are required by both state and federal law to regularly update provider directories. The purpose of this communication is to make you aware of some additional information that health plans will begin collecting as a result of provider directory provisions in state law. The goal for health plans and providers alike is to ensure that consumers have the most up-to-date, accurate, and detailed information available when searching for an appropriate in-network provider.
The Process
The majority of health plans that operate throughout Massachusetts use a single source, Council for Affordable Quality Healthcare (CAQH), to collect provider directory information. This streamlined process simplifies provider data entry. Beginning in
mid-November 2024, providers will begin seeing the additional CAQH Provider Data Portal data entry fields required by regulations implementing Chapter 124 of the Acts of 2019.
In addition to the data that providers have historically provided to plans through CAQH or alternative platforms, and that providers must attest to every 90 days, the new data requirements include more granular information areas such as:
- Practice group affiliation
- Open/closed panel status
- Office location and operating hours
- Appointment availability
- Demographics about patients you treat
- ADA accessibility
- Languages spoken
- Gender-specific treatment
- Telehealth availability
- Age groups treated
The Role of Providers
Providers – including behavioral and mental health providers registered with CAQH – will be expected to populate these new data fields in the CAQH Provider Data Portal as they are able. Providers will be expected to populate these new data fields for
carriers that use alternative platforms instead of, or in addition to CAQH. Larger systems should begin thinking about workflows and how to operationalize these new requirements. Each health plan will share more details about their specific processes.
Provider Support and Training
On January 28, 2025, from 12:00 – 1:00 p.m., there will be a provider training webinar sponsored by the Massachusetts Health & Hospital Association, the Massachusetts Medical Society, the Massachusetts Association of Health Plans, Blue Cross and Blue
Shield of Massachusetts, Healthcare Administrative Solutions, CAQH, and the Division of Insurance.
To register for the session, please click here. The session will also be recorded.
Health Plan Responsibilities
After providers submit data through CAQH, or an alternative system for plans not using CAQH, or supplied it directly to the health plan per their request, health plans will process and integrate the information into their data systems. Due to the extensive
internal processes required for complete and accurate updates, the new directory information will be reflected in provider directories by the third quarter of 2025. More details will be shared on this process, including a timeline for when providers
can expect their updated information to appear.
Collaboration for Improving Provider Directories
We recognize that this may represent additional work for providers and health care systems, which is why health plans, providers, and the DOI are working together to minimize the administrative burden and to make sure that providers have sufficient time
to comply with the new requirements.
It is in the best interest of both providers and payers for their patients/members to have up-to-date, detailed, and accurate information about who is in the network. For this to be accomplished, providers and health plans need to work collaboratively
towards the uniform goal of improving the directories while streamlining the process to get there.
