Current through Register Vol. XLI, No. 38, September 20, 2024
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.
