SB 137, as amended, Hernandez. Health care coverage: provider directories.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A willful violation of the act is a crime. Existing law requires a health care service plan to provide a list of contracting providers within a requesting enrollee’s or prospective enrollee’s general geographic area.
Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires insurers subject to regulation by the commissioner to provide group policyholders with a current roster of institutional and professional providers under contract to provide services at alternative rates.
This bill would require health care service plans and insurers subject to regulation by the
commissioner for services at alternative rates to make a provider directory available on its Internet Web site and to update the directory weekly. The bill would require the Department of Managed Health Care and the Department of Insurance to developbegin delete a standardend delete provider directorybegin delete templateend deletebegin delete.end deletebegin insert standards.end insert By placing additional requirements on health care service plans, the violation of which is a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.
The people of the State of California do enact as follows:
Section 1367.27 is added to the Health and Safety
2Code, to read:
(a) (1) A health care service plan shall make
4available a provider directory or directoriesbegin delete whichend deletebegin insert thatend insert shall
5provide information on contracting providers, including those that
6accept newbegin delete patients.end deletebegin insert patients, pursuant to the requirements of this
7section and Section 1367.26.end insert A provider directory shall not include
8information on a provider that does not have a current contract
9with thebegin delete plan and that has not submitted a claim within the past begin insert
plan.end insert
10three months.end delete
11(2) If a plan uses different provider networks for different
12products, then the requirements of this section shall apply for each
13of the provider directories for each product. The plan shall provide
14information on different provider networks for different products
15in a manner that allows the public, enrollees, potential enrollees,
16the department, and other
state or federal agencies to identify which
17providers participate in which networks for which products.
18(2) A plan shall provide the directory or directories for the
19specific network offered for each product using a consistent method
20of network and product naming, numbering, or other classification
21method that ensures the public, enrollees, potential enrollees, the
22department, and other state or federal agencies can easily identify
23which providers participate in which networks for which products.
24A health plan shall use the same consistent classification method
25in provider contracts and communications to ensure that providers
26can identify the products and networks that they are legally
27contracted to provide services in. The classification shall be
P3 1consistent across plans in order to permit the department and other
2state or
federal agencies to construct multiplan directories.
3(3) Thebegin delete information regarding aend delete
provider directory or directories
4shall be availablebegin insert on the plan’s Internet Web siteend insert to the public and
5potential enrollees without any requirement that a member of the
6public or potential enrollee indicate intent to obtain coverage from
7the plan. The directory or directories shall be available to the public
8without requiring that an individualbegin delete intends to purchase coverage begin insert seeking the directory information
9or has coverage by providingend delete
10demonstrate coverage with the plan, provideend insert
a policybegin delete number orend delete
11begin insert number, provideend insert any other identifyingbegin delete information and without begin insert information, orend insert create or access an
12requiring an individual toend delete
13account.
14(b) (1) The provider directory or directories shall bebegin delete postedend delete
15begin insert accessibleend insert
on the plan’s public Internet Web site through a clearly
16identifiable link or tab and in a manner that is accessible and
17searchable by the public, potential enrollees,begin delete enrolleesend deletebegin insert enrollees,end insert
18 and providers.begin insert The plan’s public Internet Web site shall allow for
19provider searches by name, practice address, National Provider
20Identification number, California license, facility or identification
21number, product, tier, provider language, medical group, or
22independent practice association, hospital, or clinic, as
23appropriate.end insert If another technology emerges that takes the place
24 of Internet Web sites, the department shall direct the plan to make
25the information required under
this section available on the
26subsequentbegin delete technology.end deletebegin insert
technology in a timeframe that allows for
27implementation of the technology, not to exceed six months.end insert The
28plan shall also make abegin delete hardend deletebegin insert paperend insert copy of the directory or
29directories available upon request.
30(2) The plan shall updatebegin delete weeklyend delete the provider directory or
31begin delete directories postedend deletebegin insert directories, at least weekly,end insert pursuant to paragraph
32(1) with any change to contracting providers, includingbegin delete whetherend delete
33begin insert
all of the following:end insert
34begin insert(A)end insertbegin insert end insertbegin insertInstances whereend insert a contracting provider is begin insertno longer end insert
35 accepting newbegin delete patients.end deletebegin insert patients, or that the provider moved or
36relocated from the contracted service area of the plan, or has
37retired or has otherwise ceased to practice.end insert
38(B) Instances where the
contracting provider group, if any, has
39identified that the provider is no longer associated with the group
40or is no longer accepting new patients.
P4 1(C) Instances where the plan identified a change based on an
2enrollee complaint that a provider was not accepting new patients
3or was otherwise not available.
4(D) Any other relevant information that has come to the attention
5of the plan affecting the content of the provider directory.
6(3) The provider directory or directories shall include both an
7email address and a telephone number for members of the public
8begin insert
and providersend insert to notify the plan if the provider directory
9information appears to be inaccurate.
10(4) By September 15, 2016, or no later than six months after
11the date thatbegin delete a standardend delete provider directorybegin delete template isend deletebegin insert standards
12areend insert developed under subdivision (d), a plan shall use thebegin delete templateend delete
13 developedbegin insert
standardsend insert pursuant to subdivision (d)begin delete to display the for each product offered by the
14provider directory or directoriesend delete
15plan.
16(c) begin deleteThe end deletebegin insert A full service health care service end insertplan shallbegin delete provideend delete
17begin insert includeend insert all of the following informationbegin delete for each of the provider begin insert
in the provider directory or
18directories used for a network:end delete
19directories:end insert
20(1) The provider’sbegin delete locationend deletebegin insert name, location(s),end insert and contact
21information.
22(2) Type of practitioner.
end insertbegin insert23(3) National Provider Identification number.
end insertbegin insert24(4) California license number and type of license.
end insert25(2)
end delete26begin insert(5)end insert The area of specialty, including board certification, if any.
27(3)
end delete28begin insert(6)end insert (A) For physicians, the medical group, if any.
29(B) begin deletePsychologists, end deletebegin insertNurse
practitioners, physician assistants,
30psychologists, end insertacupuncturists, optometrists, podiatrists,
31chiropractors, licensed clinical social workers, marriage and family
32therapists, professional clinical counselors, and nurse midwives
33to the extent their services may be accessed and are covered
34through the contract with the plan.
35(C) For federally qualified health centers or primary care
36clinics, the name of the federally qualified health center or clinic.
37(D) For any provider described in subparagraph (A) or (B) who
38is employed by a federally qualified health center or primary care
39clinic, and to the extent their services may be accessed and
are
40covered through the contract with the plan, the name of the
P5 1provider, and the name of the federally qualified health center or
2clinic.
3(4)
end delete
4begin insert(7)end insert Hospital admitting privileges, if any, for physicians and
5other health professionals contracted with thebegin delete plan.end deletebegin insert
plan whose
6scope of services for the plan include admitting patients and who
7have admitting privileges at a hospital.end insert
8(5)
end delete
9begin insert(8)end insert Non-English language, if any, spoken by a health
10professional as well as non-English language, if any, spoken by
11staff to the provider.
12(6) Access for persons with disabilities.
end delete
13(7) Whether a provider is accepting new patients with the
14product selected by the enrollee or potential enrollee.
15(9) Whether a provider is accepting new patients with the
16product selected by the enrollee or potential enrollee.
17begin insert(10)end insertbegin insert end insertbegin insertNetwork tier to which the provider is assigned, if
18applicable. “Tiered provider network” means a network of
19participating providers that has been divided into subgroupings
20differentiated by the health plan according to enrollee cost-sharing
21levels or quality scores. Nothing in this section shall be construed
22to require the use of network tiers other than contract and
23noncontracting tiers.end insert
24(11) A disclosure that enrolles are entitled to full and equal
25access to covered services, including
enrollees with disabilities
26as required under the Americans with Disabilities Act and Section
27504 of the Rehabilitation Act.
28(12) All other information necessary to conduct a search
29pursuant to subdivision (b).
30(d) A specialized health care service plan shall include all of
31the following information for each of the provider directories used
32by the plan for its networks:
33(1) The provider’s name, location, and contact information.
end insertbegin insert34(2) Type of Practitioner.
end insertbegin insert35(3) National Provider Identification number.
end insertbegin insert36(4) California license number and type of license.
end insertbegin insert37(5) The area of specialty, including board certification, if any.
end insertbegin insert
38(6) If participating in a group practice, the name of the group
39practice.
P6 1(7) The names of any allied health care professionals to the
2extent their services are covered through the contract with the
3plan.
4(8) Non-English language, if any, spoken by a health provider
5as well as non-English language, if any, spoken by staff.
6(9) Whether a provider is accepting new patients enrolled in
7the product that the directory applies to.
8(10) A disclosure that enrollees are entitled to full and equal
9access to covered services, including enrollees with disabilities
10as required under the Americans with Disabilities Act and Section
11504 of the
Rehabilitation Act.
12(d)
end delete
13begin insert(e)end insert (1) By March 15, 2016, the department and the Department
14of Insurance shall developbegin delete a standardend delete
provider directorybegin delete templateend delete
15begin insert standardsend insert for purposes of paragraph (3) of subdivision (b).begin delete The
16template shall include a glossary of terms used in the template.
17The template shall include information on how to contact the plan
18and the department.end delete
19(2) Thebegin delete templateend deletebegin insert standardsend insert shall bebegin delete sufficiently standardizedend delete
20begin insert
sufficientend insert to permit a single uniformbegin insert electronicend insert directory that would
21allow a member of the public to determine whether a physician or
22other provider is available to an enrollee of the California Health
23Benefit Exchange as well as a beneficiary of the Medi-Cal program
24enrolled in a Medi-Cal managed care plan. Thebegin delete template shall also begin insert standards shall be sufficientend insert to permit
25be sufficiently standardizedend delete
26a single uniform directory that would allow a member of the public
27to determine whether a physician or other provider is available to
28an enrollee with group coverage as well as to a beneficiary of the
29
Medi-Cal program enrolled in a Medi-Cal managed care plan or
30to an enrollee of the California Health Benefit Exchange.
31(3) The department and the Department of Insurance shall seek
32input from interested parties, including holding at least one public
33meeting. In developing the directory template, the department shall
34take into consideration any requirements for provider directories
35established by the federal Centers for Medicare and Medicaid
36Services.
37(e)
end delete
38begin insert(f)end insert (1) The plan shall provide the directory or directories
to the
39department in a format and manner to be specified by the
40department.
P7 1(2) The plan shall demonstrate no less than quarterly to the
2department that the information provided in the provider directory
3or directories is consistent with the information required under
4Sections 1367.03 and 1367.035, and other provisions of this
5chapter. The plan shall assure that other information reported to
6the department is consistent with the information provided to
7enrollees, potential enrollees, and the department pursuant to this
8section.
9(3) The plan shall demonstrate to the department that enrollees
10or potential enrollees seeking a provider that is contracted with
11the network for a particular product can identify these providers
12and that the provider is accepting new patients.
The plan shall
13ensure that the accuracy of the provider directory meets or exceeds
1497 percent.
15(4) The plan shall contact any provider which is listed in the
16provider directory and which has not submitted a claim within the
17begin delete prior quarterend deletebegin insert past three months for primary care providers, or six
18months for specialty care providers,end insert to determine whether the
19provider is accepting patients or referrals from thebegin delete plan.end deletebegin insert plan, if
20claims are paid by the plan. If claims are not paid by the plan, the
21plan shall contact any provider that is listed in the
provider
22directory who has not submitted encounter data within the past
23three months for primary care providers, or six months without
24encounter data for a specialty care provider.end insert If the provider does
25not respond within 30 days, the plan shall remove the provider
26from the provider directory.begin insert This requirement does not apply to
27claims or encounter data from new primary care providers in the
28first three months, or new specialty care providers in the first six
29months, of the contract.end insert
30(f)
end delete
31begin insert(g)end insert The plan shallbegin delete provideend deletebegin insert
make availableend insert an electronic copy
32of, or upon request, one physical copy of the provider directory or
33directories to the following:
34(1) To the State Department of Health Care Services for
35Medi-Cal managed carebegin delete networks.end deletebegin insert plans.end insert
36(2) To the California Health Benefit Exchange for the networks
37of the products offered through the California Health Benefit
38begin delete Exchange.end deletebegin insert Exchange, as required by contract.end insert
39(3) On request bybegin delete CalPERS, to CalPERS.end deletebegin insert the Public Employees’
40Retirement System, to the Public Employees’ Retirement System.end insert
P8 1(4) The department and the Department of Insurance.
end insert2(4)
end delete
3begin insert(5)end insert On request by a group purchaser, provider
directory or
4directories for the products available in the market segment of the
5group.
6(g)
end delete
7begin insert(h)end insert If a contracting provider, or the representative of a
8contracting provider, informs an enrollee or potential enrollee that
9the provider is not accepting new patients, the contract between
10the plan and the provider shall require the provider to direct the
11enrollee or potential enrollee to the plan for additional assistance
12in finding a provider and also to the department to inform it of the
13possible inaccuracy in the provider directory. If an enrollee or
14potential enrollee informs a plan of a
possible inaccuracy in the
15provider directory or directories, the plan shall undertakebegin insert immediateend insert
16 corrective action tobegin delete assureend deletebegin insert ensureend insert the accuracy of the directory or
17directories.
18(h)
end delete
19begin insert(i)end insert This section does not prohibit a plan from requiring its
20contracting providers, contracting provider groups, or contracting
21specialized health care
plans to satisfy the requirements of this
22section. If a plan delegates the responsibility of complying with
23this section to its contracting providers, contracting provider
24groups, or contracting specialized health care plans, the plan shall
25ensure that the requirements of this section are met.
26(j) Every health care service plan shall ensure processes are in
27place to allow providers to promptly verify or submit changes to
28demographic information and participation status. Those processes
29shall, at a minimum, include an online interface for providers to
30submit verification or changes electronically and shall allow
31providers to receive an acknowledgment of receipt from the health
32care service plan. Providers shall verify or submit changes to
33demographic information and participation status using this
34process according to the terms of
their contract with the contracted
35health plan. Providers shall verify or submit changes to
36demographic information and participation status using this
37process according to the terms of their contract with the contracted
38health plan.
39(i)
end delete
P9 1begin insert(k)end insert Every health care service plan shall allow enrollees to request
2the information required by this section through their toll-free
3telephonebegin delete numberend deletebegin insert number, electronically,end insert or in writing. On
request
4of an enrollee or potential enrollee, the plan shall provide the
5information required underbegin insert subdivisionsend insert (a), (b),begin delete (c)end deletebegin insert (c),end insert
and (g)
6in written form. The information provided in written form may be
7limited to the geographic region in which the enrollee or potential
8enrollee resides or intends to reside.
Section 10133.15 is added to the Insurance Code, to
10read:
(a) (1) A health insurer that contracts with providers
12for alternative rates of payment pursuant to Section 10133 shall
13make available a provider directory or directoriesbegin delete whichend deletebegin insert thatend insert shall
14provide information on contracting providers, including those that
15accept newbegin delete patients.end deletebegin insert patients pursuant to the requirements of this
16section and Section 10133.1.end insert A provider directory shall
not include
17information on a provider that does not have a current contract
18with thebegin delete insurer and that has not submitted a claim within the past begin insert
insurer.end insert
19three months.end delete
20(2) If an insurer uses different provider networks for different
21products, then the requirements of this section shall apply for each
22of the provider directories for each product. The insurer shall
23provide
information on different provider networks for different
24products in a manner that allows the public, enrollees, potential
25enrollees, the department, and other state or federal agencies to
26identify which providers participate in which networks for which
27products.
28begin insert(2)end insertbegin insert end insertbegin insertAn insurer shall provide the directory or directories for the
29specific network offered for each product using a consistent method
30of network and product naming, numbering, or other classification
31method that ensures the public, enrollees, potential enrollees, the
32department, and other state or federal agencies can easily identify
33which providers participate in which networks for which products.
34An insurer shall use the
same consistent classification method in
35provider contracts and communications to ensure that providers
36can identify the products and networks that they are legally
37contracted to provide services in. The classification shall be
38consistent across plans in order to permit the department and other
39state or federal agencies to construct multiplan directories.end insert
P10 1(3) Thebegin delete information regardingend delete provider directory or directories
2shall be availablebegin insert on the insurer’s Internet Web siteend insert to the public
3and potential enrollees without any requirement that a member of
4the public or potential enrollee indicate intent to obtain coverage
5from the insurer. The directory or directories shall be available to
6the
public without requiring that an individualbegin delete intends to purchase begin insert seeking the directory
7coverage or has coverage by providingend delete
8information demonstrate coverage with insurer, provideend insert a policy
9begin delete number orend deletebegin insert number, provideend insert any other identifyingbegin delete information and begin insert information, orend insert create or access
10without requiring an individual toend delete
11an account.
12(b) (1) The provider directory or directories shall bebegin delete postedend delete
13begin insert accessibleend insert on the insurer’s public Internet Web site through a
14clearly identifiable link or tab and in a manner that is accessible
15and searchable by the public, potential enrollees, enrollees, and
16providers.begin insert The insurer’s public Internet Web site shall allow for
17provider searches by name, practice address, National Provider
18Index number, California license number, facility or identification
19number, product, tier, provider language, medical group, or
20independent practice association, hospital, or clinic, as
21appropriate.end insert If another technology emerges that takes the place
22of Internet Web
sites, the department shall direct the insurer to
23make the information required under this section available on the
24subsequentbegin delete technology.end deletebegin insert
technology in a timeframe that allows for
25implementation of the technology, not to exceed six months.end insert The
26insurer shall also make abegin delete hardend deletebegin insert paperend insert copy of the directory or
27directories available upon request.
28(2) The insurer shall updatebegin delete weeklyend delete the provider directorybegin delete or begin insert directories, at least weekly,end insert posted pursuant to paragraph
29directoriesend delete
30(1) with any change to contracting providers, includingbegin delete whetherend delete
31begin insert
all of the following:end insert
32begin insert(A)end insertbegin insert end insertbegin insertInstances whereend insert a contracting providerbegin delete isend deletebegin insert has notified the
33insurer that the provider no longer intents to participate as a
34contracting provider, is no longerend insert accepting newbegin delete patients.end deletebegin insert patients,
35that the provider moved or relocated from the contracted service
36area of the plan, or has retired or otherwise ceased to practice.end insert
37(B) Instances where the contracting provider group, if any, has
38identified that the provider is no longer associated with the group
39or is no longer accepting new patients.
P11 1(C) Instances where the plan identified a change based on an
2enrollee complaint that a provider was not accepting new patients
3or was otherwise not available.
4(D) Any other relevant information that has come to the attention
5of the plan affecting the content of the provider directory.
6(3) The provider directory or directories shall include both an
7email address and a telephone number for members of the public
8begin insert
and providersend insert to notify the insurer if the provider directory
9information appears to be inaccurate.
10(4) By September 15, 2016, or no later than six months after
11the date thatbegin delete a standardend delete provider directorybegin delete template isend deletebegin insert standards
12areend insert developed under subdivision (d), an insurer shall use the
13begin delete templateend delete developedbegin insert
standardsend insert pursuant to subdivision (d)begin delete to display for each product offered by
14the provider directory or directoriesend delete
15the insurer.
16(c) The insurer shallbegin delete provideend deletebegin insert
includeend insert all of the following
17informationbegin delete for each of the provider directories used for a network:end delete
18begin insert in the provider directory or directories:end insert
19(1) The provider’sbegin delete locationend deletebegin insert name, location,end insert and contact
20information.
21(2) Type of practitioner.
end insertbegin insert22(3) National Provider Identification number.
end insertbegin insert23(4) California license number and type of license.
end insert24(2)
end delete25begin insert(5)end insert The area of specialty, including board certification, if any.
26(3)
end delete27begin insert(6)end insert (A) For physicians, the medical group, if any.
28(B) begin deletePsychologists, end deletebegin insertNurse practitioners, physician assistants,
29psychologists, end insertacupuncturists, optometrists, podiatrists,
30
chiropractors, licensed clinical social workers, marriage and family
31therapists, professional clinical counselors, and nurse midwives
32to the extent their services may be accessed and are covered
33through the contract with the insurer.
34(C) For federally qualified health centers or primary care
35clinics, the name of the federally qualified health center or clinic.
36(D) For any provider described in subparagraph (A) or (B) who
37is employed by a federally qualified health center or primary care
38clinic, and to the extent their services may be accessed and are
39covered through the contract with the plan, the name of the
P12 1provider, and the name of the federally
qualified health center or
2clinic.
3(4)
end delete
4begin insert(7)end insert Hospital admitting privileges, if any, for physicians and
5other health professionals contracted with thebegin delete insurer.end deletebegin insert insurer
6whose scope of services for the plan include admitting patients
7and who have admitting privileges at a hospital.end insert
8(5)
end delete
9begin insert(8)end insert Non-English language, if any, spoken by a health
10professional as well as non-English language, if any, spoken by
11staff to the provider.
12(6) Access for persons with disabilities.
end delete
13(7) Whether a provider is accepting new patients with the
14product selected by the enrollee or potential enrollee.
15(9) Whether a provider is accepting new patients with the
16product selected by the enrollee or potential enrollee.
17(10) Network tier that the provider is assigned to, if applicable.
18“Tiered provider network” means a network of participating
19providers that has been divided into subgroupings differentiated
20by the insurer according to enrollee cost-sharing levels or quality
21scores. Nothing in this section shall be construed to require the
22use of network tiers other than contracting and noncontracting
23tiers.
24(11) A disclosure that insureds are entitled to full and equal
25access to covered services, including insureds with disabilities as
26required under the Americans with Disabilities Act and Section
27504 of the
Rehabilitation Act.
28(12) All other information necessary to conduct a search
29pursuant to subdivision (b).
30(d) A specialized insurer shall include all of the following
31information for each of the provider directories used by the insurer
32for its networks:
33(1) The provider’s name, location(s), and contact information.
end insertbegin insert34(2) Type of practitioner.
end insertbegin insert35(3) National Provider Identification number.
end insertbegin insert36(4) California license number and type of license.
end insertbegin insert37(5) The area of specialty, including board certification, if any.
end insertbegin insert
38(6) If participating in a group practice, the name of the group
39practice.
P13 1(7) The names of any allied health care professionals to the
2extent their services are covered through the contract with the
3plan.
4(8) Non-English language, if any, spoken by a health
5professional as well as non-English language, if any, spoken by
6staff.
7(9) Whether a provider is accepting new patients enrolled in
8the product that the directory applies to.
9(10) A disclosure that insureds are entitled to full and equal
10access to covered services, including insureds with disabilities as
11required under the Americans with Disabilities Act and Section
12504 of the Rehabilitation Act.
13(d)
end delete
14begin insert(e)end insert (1) By March 15, 2016, the Department of Managed Health
15Care and the department shall develop abegin delete standardend delete
provider directory
16begin delete templateend deletebegin insert
standardsend insert for purposes of paragraph (3) of subdivision
17(b).begin delete The template shall include a glossary of terms used in the
18template. The template shall include information on how to contact
19the plan and the department.end delete
20(2) Thebegin delete templateend deletebegin insert standardsend insert shall bebegin delete sufficiently standardizedend delete
21begin insert
sufficientend insert to permit a single uniformbegin insert electronicend insert directory that would
22allow a member of the public to determine whether a physician or
23other provider is available to an enrollee of the California Health
24Benefit Exchange as well as a beneficiary of the Medi-Cal program
25enrolled in a Medi-Cal managed care plan. Thebegin delete template shall also begin insert standards shall be sufficientend insert to permit
26be sufficiently standardizedend delete
27a single uniform directory that would allow a member of the public
28to determine whether a physician or other provider is available to
29an enrollee with group coverage as well as to a
beneficiary of the
30Medi-Cal program enrolled in a Medi-Cal managed care plan or
31to an enrollee of the California Health Benefit Exchange.
32(3) The department and the Department of Managed Health
33Care shall seek input from interested parties, including holding at
34least one public meeting. In developing the directory template, the
35Department of Managed Health Care shall take into consideration
36any requirements for provider directories established by the federal
37Centers for Medicare and Medicaid Services.
38(e)
end delete
P14 1begin insert(f)end insert (1) The
insurer shall provide the directory or directories to
2the department in a format and manner to be specified by the
3department.
4(2) The insurer shall demonstrate no less than quarterly to the
5department that the information provided in the provider directory
6or directories is consistent with the information required under
7Section 10133.5 and other provisions of this part. The insurer shall
8assure that other information reported to the department is
9consistent with the information provided to enrollees, potential
10enrollees, and the department pursuant to this section.
11(3) The insurer shall demonstrate to the department that enrollees
12or potential enrollees seeking a provider that is contracted with
13the network for a particular product can identify these providers
14and that the
provider is accepting new patients. The insurer shall
15ensure that the accuracy of the provider directory meets or exceeds
1697 percent.
17(4) The insurer shall contact any provider which is listed in the
18provider directory and which has not submitted a claim within the
19begin delete prior quarterend deletebegin insert past three months for primary care providers, or six
20months for specialty care providers,end insert to determine whether the
21provider is accepting patients or referrals from thebegin delete plan.end deletebegin insert plan, if
22claims are paid by the insurer.end insert If the provider does not
respond
23within 30 days, the insurer shall remove the provider from the
24provider directory.begin insert This requirement does not apply to claims or
25claim data from new primary care providers in the first three
26months, or new specialty care providers in the first six months, of
27the contract.end insert
28(f)
end delete
29begin insert(g)end insert The insurer shallbegin delete provideend deletebegin insert
make availableend insert an electronic copy
30of, or upon request, one physical copy of the provider directory or
31directories to the following:
32(1) To the State Department of Health Care Services for
33Medi-Cal managed carebegin delete networks.end deletebegin insert plans.end insert
34(2) To the California Health Benefit Exchange for the networks
35of the products offered through the California Health Benefit
36begin delete Exchange.end deletebegin insert Exchange, as required by contract.end insert
37(3) On request bybegin delete CalPERS, to CalPERS.end deletebegin insert the Public Employees’
38Retirement System, to end insertbegin insertthe Public Employees’ Retirement System.end insert
39(4) The department and the Department of Managed Health
40Care.
P15 1(4)
end delete
2begin insert(5)end insert On request by a group purchaser, provider directory or
3directories for the products available in the market segment of the
4group.
5(g)
end delete
6begin insert(h)end insert If a contracting provider, or the representative of a
7contracting provider, informs an enrollee or potential enrollee that
8the provider is not accepting new patients, the contract between
9the insurer and the provider shall require the provider to direct the
10enrollee or potential enrollee to the insurer for additional assistance
11in finding a provider and also to the department to inform it of the
12possible inaccuracy in the provider directory. If an
enrollee or
13potential enrollee informs an insurer of a possible inaccuracy in
14the provider directory or directories, the insurer shall undertake
15begin insert immediateend insert corrective action tobegin delete assureend deletebegin insert
ensureend insert the accuracy of the
16directory or directories.
17(h)
end delete
18begin insert(i)end insert This section does not prohibit an insurer from requiring its
19contracting providers, contracting provider groups, or contracting
20specialized health care plans to satisfy the requirements of this
21section. If an insurer delegates the responsibility of complying
22with this section to its contracting providers, contracting provider
23groups, or contracting specialized health care plans, the insurer
24shall ensure that the requirements of this section are met.
25(j) Every insurer shall ensure processes are in place to allow
26providers to promptly verify or submit changes to demographic
27information and participation status. Those processes shall, at a
28minimum, include an online interface for providers to submit
29verification or changes electronically and shall allow providers
30to receive an acknowledgment of receipt from the health insurer.
31Providers shall verify or submit changes to demographic
32information and participation status using this process according
33to the terms of their contract with the insurer.
34(i)
end delete
35begin insert(k)end insert Every health insurer
shall allow enrollees to request the
36information required by this section through their toll-free
37telephonebegin delete numberend deletebegin insert
number, electronically,end insert or in writing. On request
38of an enrollee or potential enrollee, the insurer shall provide the
39information required underbegin insert subdivisionsend insert (a), (b), (c), and (g) in
40written form. The information provided in written form may be
P16 1limited to the geographic region in which the enrollee or potential
2enrollee resides or intends to reside.
No reimbursement is required by this act pursuant to
4Section 6 of Article XIII B of the California Constitution because
5the only costs that may be incurred by a local agency or school
6district will be incurred because this act creates a new crime or
7infraction, eliminates a crime or infraction, or changes the penalty
8for a crime or infraction, within the meaning of Section 17556 of
9the Government Code, or changes the definition of a crime within
10the meaning of Section 6 of Article XIII B of the California
11Constitution.
O
98