July 05, 2022
Area(s) of Interest: Payor Issues and Reimbursement
Since 2016, California health plans and insurers have been required to comply with uniform standards and provide timely updates for their provider directories, as required by SB 137. As part of the requirements, plans/insurers must regularly contact contracting providers to advise them of the information the payor has about them in the directory.
While under state law the interval for these communications had been either every 180 days or annually, depending on the size of the practice, a new federal law took effect in January 2022 that now requires health plans/insurers to verify the accuracy of their contracting providers’ demographic information every 90 days.
Providers who fail to comply with the verification requests risk payment delays and removal from the provider directory. Health plans or insurers may also terminate a contract with a provider for a pattern or repeated failure to update the required information.
In addition to reviewing/updating you practice information at least every 90 days, practices should also note that if the practice is moving, adding or losing providers, changing the practice name and/or TIN, closing a practice or changing specialties, it’s important to inform payors with at least 90 days advance notice to prevent payment issues.
Under SB 137, health plans/insurers operating in California are also required to offer an electronic method to allow providers to verify or submit changes to their directory information.
The California Medical Association (CMA) queried the major payors on their processes for updating provider demographic information and compiled their processes into a resource for physicians, “Updating Provider Demographic Information with Payors,” which is available free to CMA members.