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Which plans/lines of business do the regulations apply to?
The regulation applies to all fully insured managed care commercial plans issued to individuals or employers in Massachusetts, including Connector Care plans but does
not apply to large employer self-funded plans, government plans such as MassHealth, Medicare Advantage, or out of state plans.
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Which providers are subject to the regulation?
Providers who contract with health plans and who are listed in traditional commercial health insurance provider directories to help consumers to choose a clinician are subject to the
regulation. Examples include primary care physicians, psychologists, orthopedists, and speech therapists. Pediatric dentists may be listed when they participate with a health plan to provide dental services to children. Generally, if a consumer
does not normally choose to make an appointment with the provider, then the provider does not have to enter their provider directory information. Examples include pathologists, hospitalists, anesthesiologists, radiologists, emergency department
physicians, physicians who only see patients at nursing homes, and dentists who are contracted with dental insurance plans.
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Which health plans do not use CAQH? Do I have to complete different information for those plans?
Aetna and Cigna currently do not use CAQH for their provider directories. The Division of Insurance (DOI) is working with these plans
to ensure that their directory validation processes are not significantly different from CAQH and align with the DOI’s regulations.
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For plans that use CAQH, if I enter all of my information, attest, and provide updates as necessary in the portal, that should be everything that the health plan requires, and I should not receive additional requests or separate forms to complete.
Is that correct?
There are a limited number of fields that are not currently being supported by CAQH such as whether or not a provider practices concierge medicine. To obtain that additional information, a carrier may separately
contact providers. There are also limited situations when a change in a provider’s information may necessitate outreach to update a provider contract (e.g., addition of a new provider to an existing provider group).
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Are the provider directories available only to members of that health plan or to the general public?
A health plan’s provider directory is available to members of that health plan as well as to the general public so that potential
members can determine whether their clinicians are in a plan’s network.
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Once this is fully implemented in approximately the third or fourth quarter of 2025, what is the timeline for health plans to update the data that providers send through CAQH?
Per the DOI regulation, provider directories must be updated
as soon as practicable and not less often than monthly or as directed by the Commissioner; provided, however, that an electronic Network plan Provider directory shall be updated within two business days, or sooner if consistent with federal
guidelines, when the Carrier is informed of and upon confirmation that:
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A contracting Provider is no longer accepting new patients for that Network plan or an individual Provider within a Provider group is no longer accepting new patients;
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a Provider or Provider group is no longer being under contract for a particular Network plan;
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a Provider's practice location or other Provider directory information has changed;
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a Provider has retired or ceased practice; or
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any other information that affects the content or accuracy of the Provider directory has changed.
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What address should I put in CAQH if I practice only telehealth?
CAQH can flag when a provider is telehealth only and no address is necessary. In terms of displaying an address in the provider directory, telehealth providers who do
not also see patients in person should not include an address for purposes of the provider directory. Plans that do not use CAQH also have logic to indicate telehealth only so that no home address is necessary.
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If I do not see patients and do not bill an insurer, do I still have to put my information in CAQH?
No, providers who do not contract with insurers do not need to enter information into the CAQH portal as they will not be listed in
a provider directory.
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Are there plans to standardize the process for facilities?
No, there are no immediate plans to add facilities to CAQH. CAQH was designed to standardize the intake of information for individual clinicians. Health Plans collect information
about facility and other non-clinician providers (including hospitals, community health centers, medical groups, behavioral health hospitals, skilled nursing facilities, rehabilitation facilities, laboratories, MRI centers, and urgent care
facilities) independent of CAQH and display that information in the directories.
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Are psychiatric NPs required to have a hospital affiliation or admitting hospital?
No hospital affiliation is required under this circumstance.
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We are a pediatric practice that sees patients through age 23 but we only accept new patients under age 18. How would I reflect this in the directory?
These are reflected in two separate questions in CAQH; one asks about the ages
a provider treats and the other asks whether a practice is open to new patients. Currently CAQH does not allow a provider to respond to availability based on specific factors such as the age of a patient. We recommend that if a practice is
open to the majority of patients based on age that the provider consider being listed as available to take new patients.
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How do I reflect the fact that my ability to accept new patients is very fluid. For example, as a psychotherapist, when someone completes therapy I have an opening, but it may not be available for a month or longer. How do I answer the “accepting
new patients” question?
If you believe you can see a new patient within a reasonable time frame, you can indicate that you are accepting new patients, or you can list your practice as not accepting new patients and then update it
in CAQH when the situation changes.
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I am concerned about confidentiality around treatment of specific groups. Who else would have access to this information?
This question is optional and does not require the provider to respond. A provider may volunteer to have this
listed in the provider directory or they can skip the question.
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Health plans are on different schedules regarding the 90-day directory attestation. Will this be streamlined so I’m only doing it once every 90 days rather than multiple times for each health plan?
For data in CAQH, you will receive
reminder emails on a rolling basis every 90 days based off the date of your last directory attestation, prompting you to update and attest to the accuracy of your directory information. Each email will represent all the health plans using
CAQH with whom you contract.
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I am based in Rhode Island but see patients in Massachusetts. Do I need to enter my information?
Yes, if you are contracted with any of the Massachusetts health plans that come under this regulation, you must enter your information
for the provider directories.
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Under what circumstances is a practice/provider’s information suppressed and what is the process for getting it re-listed in the directory?
In general, providers must attest to the accuracy of the information in the provider directory
every 90 days. If, after several attempts, the health plan is unable to obtain the attestation, the health plan may suppress the provider’s information from the provider directory. If a provider finds that their information has been suppressed,
they should re-attest to their data through CAQH so that they get re-listed in the directory.
