145.035 Health Plan Provider Directories


Health Plan Provider Directories: All health plans should maintain current and accurate provider directories. To maintain the directories, the health plans should adhere to certain guidelines:

All health plans should use the credentialing information they obtain from physicians to maintain their provider directories.

All health plans should use one primary address as a point of contact when verifying information that will be used within their provider directory. This primary address should be designated by the physician either through the credentialing process or the contracting process with the health plan.

All health plans should clarify how they categorize physicians by specialty within their provider directories and how physicians may request to be listed under a separate or additional specialty.

All health plans should clarify how they accept, review, and implement changes to their provider directory if the changes are submitted by health plan enrollees. The health plan should offer the opportunity for physicians to review and approve these changes before publication. The review period should be no shorter than 30 days from the date of notification to the physician about the proposed changes.

All health plans should offer physicians both online and written processed for updating their provider directory information if the information changes before the physician’s next recredentialing cycle. These processes should be easily accessible on the public portion of the health plan website and included in the health plan’s administrative guide. Physicians should be able to submit changes at least 30 days in advance of the effective date. The health plan should provide written acknowledgement to show receipt of the changes as requested, a date as to when the changes take effect, and if the changes will also require a change in the physician’s contract agreement with the health plan.

All health plans should not terminate or remove physicians from their provider directories during the Medicare and Qualified Health Plans yearly open enrollment time frames that the Centers for Medicare and Medicaid Services establishes.

All health plans should not use the accuracy of the information in the provider directories as the sole basis of terminating or removing the physician from their network(s).

All health plans that list physicians under multiple practice locations shall verify that all the practice locations are applicable to the physician.

The Texas Medical Association opposes any health plan processes that place an undue administrative burden on the physician to maintain the accuracy of health plan provider directories.

TMA opposes any health plan processes that penalize a physician who relies on a health plan directory to locate or make a referral to an in-network provider (CSE Rep. 2-A-16).

Last Updated On

June 20, 2019