Section 52.15 - Provider DirectoriesAll Provider directory requirements set forth in 211 CMR 52.15 shall be in addition to any applicable Provider directory requirements under 211 CMR 152.08 for insured Health Benefit Plans that use limited, regional or tiered Provider Networks:
(1) Carriers shall establish appropriate systems to collect, store, and maintain detailed information about each Health Care Provider within their Provider Network systems. The systems are to be developed in a manner that facilitates a Health Care Provider's ability to update personal and practice information to the maximum extent feasible. Carriers shall ensure that Provider directories educate persons covered by plans providing services through Networks of Providers about how they may obtain in-Network care from an out-of-Network Provider when an in-Network Provider is not available.(2) The detailed information that the Carrier is required to collect, store and maintain about Health Care Providers who are a part of the Carrier's Network, shall include at least the following information for each Health Care Provider: (a) Health Care Provider's primary Specialty, secondary Specialty (if applicable), tertiary Specialty (if applicable), Behavioral Health sub-Specialty (if applicable) 1. The reporting of a Specialty or sub-Specialty should be based on the Provider's actual training and experience in treatment of this Specialty or sub-Specialty in the past 24 months.;(b) license type, practice credentials (education, including all relevant licensure(s), professional designations, and relevant certifications, including but not limited to board certifications);(c) Health Care Facilities with which a Health Care Provider is affiliated (e.g., where a Provider has admitting privileges);(d) if a hospital or Facility, the type of hospital\Facility and its Accreditation status;(e) if a non-hospital behavioral health Facility, the standard services as identified by the Commissioner, that are available in the Facility;(f) practice group affiliation;(g) office locations for a Provider, and for each location whether the individual Providersees patients in that location: 1. at least once per week;2. at least once per month; or3. as a cover/fill-in as needed;(h) whether the Health Care Provider is:1. is available to accept new patients covered by the Carrier;2. is not accepting new patients covered by the Carrier; or3. has limited availability to accept new patients covered by the Carrier with a waitlist of 4 weeks of less to schedule an appointment;(i) operating hours for each office location, including whether the office is available for evening and weekend appointments;(j) main phone number(s) available for members' use in setting up appointments;(k) all languages understood and/or spoken by the Health Care Provider;(l) whether the setting in which a Provider treats patients is ADA accessible and a description of the accommodations available to address physical, developmental, and intellectual disabilities;(m) whether the practice specializes in the treatment of specific genders and identification of those specific genders or gender identities based upon the Provider's actual treatment of members of such populations or groups in the last 24 months.;(n) any specific age groups treated by the Health Care Provider, if the Provider so chooses;(o) any special populations or cultural groups that the Health Care Provider wishes to highlight that the Health Care Provider serves, as well as the Provider's race and nationality, if the Provider so chooses;(p) whether the Health Care Provider has conditions to treating a patient, including the following: 1. requiring a patient to pay a concierge medicine fee, Facility fee, or other administrative fee in order to be treated by the Health Care Provider,2. if a Health Care Provider practice requires that the care is limited to hospital or Facility inpatients;3. for Health Care Providers who work in clinics or community health centers, requiring that a patient receive other health care at the clinic or community health center; or4. for Health Care Providers who work at university or school health centers, requiring that patients are enrolled students in the university or school.(q) if a Tiered Network Plan, the Provider's tier, an explanation of how the Carrier identifies the Provider's tier, and the impact of the tier on Cost-sharing under the health plan; and(r) which Health Care Providers within a Facility are available for consultation via Telehealth and the modalities of Telehealth the Health Care Provider offers to patients or whether the Health Care Provider is available for consultation only via Telehealth.(3) detailed information that the Carrier is required to display in the Provider directory shall present information about the Health Care Professionals who see patients at each office location identifying whether the Health Care Professional is limiting patients to a subset of the Carrier's members and information according to the following categories:a. Health Care Professional sees patients at the location at least once per week;b. Health Care Professional sees patients at the location at least once per month; andc. Health Care Professional sees patients as a cover/fill-in or when needed.(4) detailed information that the Carrier is required to display in the Provider directory shall include at least the following information about non-Facility Health Care Providers who are apart of the Carrier's Network:(a) Health Care Provider's primary Specialty, secondary Specialty (if applicable), tertiary Specialty (if applicable), Behavioral Health sub-Specialty (if applicable);(b) license type, practice credentials (education, including all relevant licensure(s), professional designations, and relevant certifications including but not limited to board certifications);(c) Health Care Facilities with which a Health Care Provider is affiliated (e.g., where a Provider has admitting privileges);(d) whether the Health Care Provider is:1. accepting new patients that are covered by the Carrier2. closed to new patients covered by the Carrier; or3. accepting new patients but with a wait list of 4 weeks or less to schedule an appointment);(e) group practice affiliations;(f) office locations for a Provider where the Provider will see patients and for each location whether the Provider sees patients: 1. at least once per week; or2. at least once per month;(g) operating hours for each office location, including whether the office is open for evening and weekend appointments;(h) phone number(s) or other contact information a member may use in setting up an appointment;(i) whether the office at which a Provider treats patients is ADA accessible and a description of the accommodations available to address physical, developmental, and intellectual disabilities;(j) languages spoken by the Health Care Provider;(k) age groups and special populations, genders or cultural groups that the Health Care Provider treats on a regular basis, as well as the Provider's race and nationality, if the Provider so chooses;(l) whether the Health Care Provider requires a patient to pay a concierge medicine, Facility fee, or other administrative fee in order to be treated by the Health Care Provider;(m) if a covered member is in a Tiered Network Plan, the Carrier shall provide access to information that will identify the Provider's tier within the covered members' Tiered Network Plan, an explanation of how the Carrier identifies the Provider's tier, and the impact of the tier on Cost-sharing under the health plan; and(n) whether the Health Care Provider is available for consultation via Telehealth and the modalities of Telehealth the Health Care Provider offers to patients.(5) The detailed information that the Carrier is required to display in the Provider directory shall include at least the following information about Facility Health Care Providers who are a part of the Carrier's Network:(a) the type of hospital/Facility and its Accreditation status;(b) if a non-hospital behavioral health Facility, the standard services as identified by the Commissioner that are available in the Facility;(c) the main phone number(s) for members to use in contacting the Facility;(d) all languages spoken by Providers within the Facility;(e) whether the office is ADA compliant and list a description of accommodations to address physical and intellectual disabilities;(f) if Facilities are tiered within a Tiered Network Plan, the Provider's tier, an explanation of how the Carrier identifies the Provider's tier, and the impact of the tier on Cost-sharing under the health plan;(g) how the Health Care Provider may be contacted by a patient, including phone numbers and internet portals; and.(h) whether the Facility's practitioners may be available for consultation via Telehealth.(6) A Carrier shall ensure the accuracy of the information concerning each Provider listed in the Carrier's Provider directories for each Network plan and shall review and update the entire Provider directory for each Network plan.(7) If delivering a paper copy of the Provider directory, a Carrier shall be deemed to have met the requirements of 211 CMR 52.15(1) if the Carrier:(a) provides to at least one adult Insured in each household, or in the case of a group policy, to the group representative, at least once per calendar year an addendum, insert, or other update to the Provider directory originally provided under 211 CMR 52.15(1);(b) updates its toll-free number within 48 hours and Internet Website as soon as practicable, or as directed by the Commissioner.(8) Every Provider directory described in 211 CMR 52.15 must contain the effective date, date of issue, expiration date, if applicable, and reference to any government-sponsored website(s) providing quality and cost information, as may be designated by the Commissioner.(9) A Carrier shall deliver a Provider directory through an Internet Website A Carrier may also deliver a Provider directory via "intranet websites," "electronic mail," and "e-mail." If the Carrier refers an Insured to access directory information through an Internet Website, the Carrier must be able to demonstrate compliance with the following: (a) The Carrier shall deliver notice of the Provider directory to at least one adult in the household of each Insured, by direct mail, or by electronic mail if the Insured has agreed to communicate electronically, that includes:1. all necessary information and a clear explanation of the manner by which Insured scan access their specific Provider directory through an Internet Website;2. a list of the specific information to be furnished by the Carrier through an Internet Website;3. the Insured's right to receive, free of charge, a paper copy of the Provider directory at any time;4. the manner by which the Insured can exercise the right to receive a paper copy at no cost to the Insured; and5. a toll-free number for the Insured to call with any questions or requests and instructions about how the Insured can contact the Carrier if they want assistance in locating an available Provider. The Carrier shall take reasonable measures to ensure that the Provider directory information and documents furnished in an Internet Website are substantially the same as that contained in the Carrier's paper documents.(b) The Carrier takes reasonable measures to ensure that it furnishes, upon request of an individual, a paper copy of the Provider directory.(10) A Provider directory that is electronically available shall:(a) be in a format which will be searchable by2. Specialty in treating specific populations, if applicable,3. whether the Provider is accepting new patients/is closed to new patients,5. distance from a geographic starting point selected by a consumer.;(b) shall identify that it is current as of a certain date;(c) be accessible to the general public through a clearly identifiable link or tab without requiring the general public to create or access an account, enter a policy or contract number, provide other identifying information, or demonstrate coverage or an interest in obtaining coverage with the Network plan;(d) be updated as soon as practicable and not less often than monthly or as directed by the Commissioner; provided, however, that an electronic Network plan Provider directory shall be updated within two business days, or sooner if consistent with federal guidelines, when the Carrier is informed of and upon confirmation that: 1. a contracting Provider is no longer accepting new patients for that Network plan or an individual Provider within a Provider group is no longer accepting new patients;2. a Provider or Provider group is no longer being under contract for a particular Network plan;3. a Provider's practice location or other Provider directory information has changed;4. a Provider has retired or ceased practice; or5. any other information that affects the content or accuracy of the Provider directory has changed.(11) A Provider directory shall include a dedicated customer service email address and telephone number and electronic link, set forth prominently in both the directory and on the Carrier's website, to assist with the Provider directory information and to provide information about a Provider's participation in the Carrier's Network, consistent with federal requirements for providing this information. The Provider directory will educate members to notify the Carrier of inaccurate Provider directory information, consistent with federal requirements. The Carrier shall investigate reports of Provider directory inaccuracies within 30 Days of receiving notice of an inaccuracy, and the Carrier shall modify the Provider directory as soon as practicable, but not longer than 30 Days after finding an inaccuracy. Carrier will establish a dedicated toll-free telephone number or add an option to its existing toll-free number to assist covered persons to schedule an appointment with an available and appropriate Health Care Provider when they are unable to locate or schedule an appointment with a Health Care Provider who is listed in the Carrier's Provider directory information as accepting new patients to treat the patients of a certain age or health condition Specialty.
The Carrier will also contact each of the Health Care Providers who were unavailable to schedule an appointment with the patient in order to understand the reasons that an appointment was not scheduled, and the Carrier shall modify the Provider directory information as necessary to reflect the correct availability of the Health Care Provider to treat conditions and certain age groups. Carriers shall conduct staff training regarding communications about inaccurate Provider information so as to ensure that Provider directory inaccuracies are promptly investigated and corrected. Carriers will maintain files of all such follow-up calls so that they may be reviewed by Division staff upon request.
(12) The Provider directory must contain a list of Health Care Providers in the Carrier's Network available to Insureds residing in Massachusetts, organized by Specialty, location, and distance from a starting point selected by the searching individual, and the directory shall summarize on the Carrier's Internet Website for each such Provider: (a) the method used to compensate or reimburse such Provider;(b) the Provider price relativity, as defined in and reported under section 10 of chapter 12C;(c) the Provider's health status adjusted total medical expenses, as defined in and reported under said section 10 of said chapter 12C;(d) current measures of the Provider's quality based on measures from the Standard Quality Measure Set, as defined in the regulations promulgated by the Center for Health Information Analysis established by M.G.L. c. 12C, § 2; provided, that the Carrier shall prominently promote Providers based on quality performance as measured by the standard quality measure set and cost performance as measured by health status adjusted total medical expenses and relative prices;(e) such information about Providers may be provided directly by Carrier or by reference to a third-party source that facilitates comparison of Providers' performance.(13) Carriers shall display information in the Provider directory about how to access coverage for community-based Behavioral Health Service Providers that provide crisis, urgent care, and stabilization services, including but not limited to mobile crisis intervention and the emergency services program.(14) Nothing in 211 CMR 52.15(8) shall be construed to require disclosure of the specific details of any financial arrangements between a Carrier and a Provider.(15) If any specific Providers or type of Providers requested by an Insured are not available in said Network, or are not a covered benefit, or if any Primary Care Provider or Behavioral Health or substance use disorder Health Care Professional is not accepting new patients, such information shall be provided in an easily obtainable manner, including in the Provider directory.(16) Notwithstanding any general or specific law to the contrary, a Carrier shall ensure that all Participating Provider Nurse Practitioners and Participating Provider Physician Assistants with whom a member can make an appointment are included and displayed in a nondiscriminatory manner in the Carrier's Provider Directory.(17) Carriers' new and renewing Provider contracts shall require Providers to inform the Carrier promptly when the Provider availability to see new patients changes (including whether they have a wait list) and Carriers shall prioritize updating directories to reflect these changes within two business days of receiving notice of a Provider's change in status.(18) Consistent with federal guidelines, Carriers shall contact Providers every 90 days, or as directed by the Commissioner, to remind Providers to check and verify their profiles so that Carriers can certify that the Provider's information is correct. As part of such reminders, Carriers shall educate Providers about the importance of making Provider changes as soon as Provider changes occur so that Carriers may make the appropriate Provider directory updates as soon as possible.(19) Consistent with federal guidelines, Carriers that have received notice of potentially inaccurate information through a consumer, Provider, or audit and have been unable to validate the accuracy of the listing shall take the following steps: (a) If the potential inaccuracy relates to the physical address or telephone number of the Provider, the Carrier should either immediately remove the information from the online directory until the information is updated, or designate the information as "unverified" for no longer than 90 days, after which the information must be immediately removed;(b) If the potential inaccuracy relates to whether a Provider is accepting new patients, the Carrier shall remove the designation "accepting new patients" for that Provider until the information is updated;(c) If the potential inaccuracy relates to whether a Provider is or continues to be an in-Network Provider, the Carrier should remove the full Provider listing from the online directory until it is updated.(20) Carriers shall employ policies to ensure that directory information provided, updated and verified by behavioral health Providers is accurately uploaded and displayed in its directory and shall audit licensed behavioral health Providers' and licensed non-hospital behavioral health facilities' Provider directory information on a quarterly basis, including information with respect to:(a) all licensed behavioral health Providers who have not submitted a claim within 12 months of the audit and who have not otherwise been audited or have not received an attestation in the past 12 months or for whom the Carrier has not received a written or electronic attestation certifying that all elements of the licensed behavioral health Provider's directory profile have been reviewed, updated as necessary and then confirmed as accurate has not been received in the past 12 months; and(b) a representative sample of no less than 15% of all licensed behavioral health Providers who have not been audited in the last 12 months or for whom as a written or electronic attestation certifying that all elements of the licensed behavioral health Provider's directory profile have been reviewed, updated, as necessary, and then confirmed as accurate has not been received in the past 120 days; and(c) Carriers should compare at least 2% of the attestations received in the prior 120 days to the related information or changes in their Provider directories to confirm that the data elements match the data elements in the directory.(21) Quarterly behavioral health audits shall exclude licensed behavioral health Providers that have been audited in the last 12 months, or which have been removed from the Provider directory. In the event that three successive quarterly audits demonstrate that at least 85% of the auditable licensed behavioral health Providers are listed in a manner that is 100% accurate, the Carrier may shift to conducting behavioral health audits on a semi-annual basis.(22) Non-behavioral Health Care Providers' Provider directory information should be audited to ensure accuracy of Provider directory information on at least an annual basis, or as directed by the Commissioner. Carriers shall initiate these required audits no later than the start of the second calendar quarter after these regulations are promulgated in final form.(23) Carriers will maintain files of all Provider audits for no less than seven years from the completion of any audit so that they may be reviewed by Division staff upon request.(24) A Carrier shall deliver a notice to at least one adult Insured in each household upon enrollment annually about how to access the Carrier's Provider directory.(25) A Carrier shall deliver a Provider directory to an Insured or a prospective Insured upon request. The print copy of the requested Provider directory information shall be provided to the requester by mail postmarked no more than five business days after the date of the request, and the print copy may be limited to the geographic region in which the requester resides or works or intends to reside or work.(26) In the case of a group policy, the Carrier shall deliver a Provider directory to the group representative on at least an annual basis.(27) A Carrier shall update the print copies of the Carrier's Provider directory not less frequently than annually, and a Carrier shall include a disclosure in the print format of the Provide rdirectory that the information included in the Provider directory is accurate as of the date of printing and that an individual may consult the Carrier's electronic Provider directory on its website or call a specified customer service telephone number to obtain the most current Provider directory information;(28) A Carrier shall not be required to deliver a Provider directory upon enrollment if a Provider directory is delivered to the prospective or current Insured, or in the case of a group policy, to the group representative, during applicable open enrollment periods.(29) A Carrier that provides specified services through a workers' compensation preferred Provider arrangement shall be deemed to have met the requirements of 211 CMR 52.15 if it has met the requirements of 211 CMR 51.00 and 452 CMR 6.00.(30) If a Carrier offers a Site of Service Plan, the Provider directory for this plan is to clearly and prominently specify which certain Network Providers or service locations will only be available for covered care when the care is deemed medically necessary to be provided by the Provider or a certain service location.Amended by Mass Register Issue 1345, eff. 8/11/2017.Amended by Mass Register Issue 1509, eff. 11/24/2023.