You should understand your responsibilities for reporting your information to health plans under current regulations. Here is a summary of provider responsibilities, for a more complete breakdown of the regulations go to Regulations.
Commercial Products (HMO, PPO, Exchange) or Medi-Cal
The contracted entity, which could be you personally, or your group practice, or an IPA you are associated with, is required to comply with California SB137. A physician cannot report to health plans for a contract signed by an IPA or a group practice, a group cannot report to health plans for contracts signed directly with the individual doctor.
For contracts for which you are directly responsible:
You need to report changes to your provider directory data to all contracted health plans as soon as they occur, the health plan must publish these changes to its online directory within 5 days of receipt. The changes you need to report are things that impact access to care such as closing your panel, moving locations, changing contact details, no longer accepting an insurance product.
The changes need to come from the contracted entity which complicates the reporting of changes. The individual doctor should inform all their affiliated groups and directly contracted health plans of any change. These affiliated groups must in turn inform any contracted health plans with whom they hold contracts. For simplicity, Sanator subscribers need only report a change once to Sanator and we will take care of all distributions.
Periodic Attestation of Provider Directory Data
California SB137 requires that health plans verify their directory data with contracted partners at least once annually for individual doctors and twice annually for groups. The statute specifies the data that the health plan must share with you for validation– including provider directory information down to a product level. The contracted partner must respond to a health plan validation request within 30 days.
Know Your Rights
- You are not required to report on data beyond the SB137 specification (download here). You may choose to provide additional data to your contracted health plan for inclusion in their directory but you are not required to do so.
- Despite the threatening language used by data collection agencies, you are not required to respond to anyone asking you for information unless the request is made on behalf of a contracted health plan, the request is compliant with SB137 and your data privacy is guaranteed. If in doubt about any request for information contact email@example.com for clarification.
- You are not required to validate data from health plans with which you do not directly hold a contract. Unless you have been appointed as a delegated administrator for another contracted entity, you are not authorized to respond on behalf of that other contracted entity, even if the response is related to your practice.
For Medicare and Medicare Advantage Products
The Center for Medicare Services (CMS) requires that health plans contact their providers at least once per quarter. The form of this contact is not specified and the information that should be exchanged is not specified. You should expect payers for Medicare products to request that you verify your provider directory information at least once per quarter.
You should expect that your payers will make this validation simple and efficient for you and your staff. If you find that this process is cumbersome in any way, please let us know at firstname.lastname@example.org and we will contact the payer to discuss alternatives.
For Workers Compensation
An insurer, employer, or entity that provides physician network services may establish or modify a medical provider network for the provision of medical treatment to injured employees. Every medical provider network shall post on its Internet Web site a roster of all treating physicians in the medical provider network and shall update the roster at least quarterly.
It is the responsibility of the provider network to maintain the quality and currency of its provider roster data. The responsibility of the provider to inform the provider network management staff of changes it typically covered in the workers compensation contract signed by the provider.
You should be familiar with your responsibilities arising from any workers compensation contracts and report data changes to the contracted entities timeously.