QuestAnalytics NSA FAQ.pdf

Protecting Patients
and Improving
the Accuracy of
Provider Directory
Information

What is the No Surprises Act?

The No Surprises Act is a federal law that seeks to
protect patients from receiving unexpected medical bills,
commonly known as “surprise bills.”

Under the section, Protecting Patients and Improving the
Accuracy of Provider Directory Information, health plans,
providers, and facilities to work together to maintain
accurate provider directories.

Why does the No Surprises Act require accurate provider directories?

Accurate provider directories help health plans, providers,
and facilities reduce member confusion about network
status and lower the likelihood of incurring costs from
surprise medical bills.

When did the provider directory requirements take effect?

The provider directory rules went into effect on
January 1, 2022, alongside other provisions of the Act.

Who is responsible for maintaining accurate provider directories?

Responsibility for provider directory accuracy is
shared between:

• Health Plans
• Providers
• Facilities

Establish a process to verify provider
directory information at least every
90 days, and a process to remove
providers who fail to update on time.

Submit provider directory information
to the health plan when they start
or end a network agreement, with
respect to certain coverage.

Update the public
directory, including
removing providers
after contract
termination or lack
of attestation.

HEALTH
PLAN
Requirements

Respond to member
inquiries regarding provider
network status, information,
and records.

PROVIDER &
FACILITY
Requirements

Provide updates upon request
or as deemed necessary by the
provider, facility, or the
Secretary of
Health and Human Services (HHS).

Send updates to
the health plan
when there are
changes to the
provider directory
information.

Responsibilities of Health Plans

What are the Provider Directory Verification Requirements?

Health plans are primarily responsible for maintaining
a publicly accessible and accurate provider directory of
in-network providers and facilities. Obligations include
directory maintenance, verification protocols, timely
updates, and member communications.

1. Maintain Accessible and Accurate Directories

• Online Directories: Maintain accurate directories
on the website in a user-friendly format.
• Printed Directories: If printed directories are
requested, they must state the last update date and
direct consumers to the public website database for
confirmation of provider participation.

2. Verify Provider Data Every 90 Days

• Health plans must verify and update provider
directory information for each provider and facility
where they hold a direct or indirect contractual
relationship. This must happen at least once every
90 days.
• Providers or facilities who fail to verify information
within the stipulated timeline must be removed
from the directory until updated information
is available.

3. Process Updates Within 2 Business Days

• Any updates submitted by providers or facilities
must be reflected in the directories within two
business days, including the removal of providers
no longer in-network.

4. Respond to Consumer Inquiries Within 1 Business Day

• When consumers inquire about a provider’s network
status, health plans must respond within one
business day.

How do providers and facilities contribute to compliance efforts?

Providers and facilities are required to support health plans
by maintaining their own business processes to submit
updated information, adhere to verification timelines, and
notify health plans about any changes in their details.

How Can Health Plans

Comply with the No

Surprises Act?

To comply with the Act, health plans must develop
repeatable, well-documented processes.

1. Establish a Provider Outreach and Attestation

Process Aligned with New Requirements

Policy: Providers must verify or update directory
data elements at least every 90 days.
• Develop a process to reach out to providers and
facilities every 90 days for verification. Align the
outreach cycle for each provider or group roster
with their most recent attestation date. Additionally,
implement a reliable method to easily integrate
data updates.
• Tailor the outreach process to meet the
preferences, procedures, and workflows of
individual providers or practices.

What information must be verified and updated in the provider directories?

At a minimum, the following must be verified
and updated:
• Provider’s Name
• Provider’s Specialty
• Provider’s Address
• Provider’s Digital Contact Information
• Whether the Provider is accepting
new patients
• Provider’s in-network or out-of-network status
Tip: The Provider’s Address should be the Service
Location Address where members can regularly
make appointments with the provider.

2. Track Provider Outreach and Response Metrics

Policy: Report provider outreach and verification activities.
Compliance depends on having defendable processes
supported by metrics that can demonstrate your
ongoing efforts.
• Provider Outreach Attempts: Record all
outreach attempts, including timing and outreach
communication methods.
• Provider Responsiveness Metrics: Track provider
responses, including the method of response, the
last attested date, and the number of days they
remained non-responsive.

Provider Outreach and Responsiveness Metrics

3. Establish a Data Management Policy

Policy: Establish a provider data management
process to remove providers from the directory
if they don’t verify their data within the
required timeframe.
We recommend categorizing providers based on their data
verification status. These categories help determine the
next steps for maintaining compliance while keeping the
directory accurate.

Categorizing Providers Based on Data Status

1. Validated Providers: Their submitted details do not
raise concerns or red flags, making them eligible to
remain in the provider directory.
2. Validated but Questionable Providers: Providers
and facilities who verify their data but have some
elements that raise concerns. These providers can
stay in the directory but it’s smart to flag them for
targeted follow-up and further verification.
3. Unverified Providers: Providers and facilities who
fail to verify their information within the required
timeframe and must be removed from the directory.

How Can Health Plans Evaluate and Improve Their Provider Directory Processes?

Start by taking a close look at your existing processes for directory updates. Pay special attention to how provider data
is collected, verified, and integrated into your systems. Identifying gaps and inefficiencies upfront will set the foundation
for improvement.
Tip: Use our Provider Directory Accuracy Assessment Toolkit to help your organization evaluate and refine your process.

Responsibilities of Providers and Facilities

Do providers and facilities have obligations under the No Surprises Act?

Yes, providers and facilities must establish business
processes to submit provider directory information at
specified times to support health plans in maintaining
accurate provider directories.

Are all providers and facilities required to submit information to update the public directory?

Yes, all providers and facilities contracted to provide
services within the applicable network must comply with
the provider directory requirements.

When must providers and facilities submit provider directory information to a health plan or issuer?

• When terminating a network agreement with a
health plan or issuer for certain coverage.
• When entering a network agreement with a health
plan or issuer for certain coverage.
• When there are material changes to the provider
directory information.
• At any other time, including upon request from the
health plan, issuer, or the Secretary of HHS.

What directory information must providers and facilities share and verify?

• Individual Providers: Name, address, specialty, elephone numbers, and digital contact information.
• Medical Groups, Clinics, or Facilities: Name,
address, telephone number, and digital contact
information for each entity contracted to participate
in plan networks.

Example:

A pulmonologist recently began a network agreement with a new health plan.

Is the pulmonologist required to submit provider directory information to the health plan?

Yes, under the Act, the pulmonologist is required
to submit provider directory information (i.e. the
provider’s name, address(es), specialty, telephone
number(s), and digital contact information) to a
health plan or issuer when they begin a network
agreement with a health plan or issuer with respect
to certain coverage.

Tips to Enhance the Provider & Health Plan Process

1. Develop a Provider Directory Policy and

Procedure Manual that outlines the provider data
verification and update methods providers and
facilities are required to follow as agreed upon with
the health plan or insurer.
2. Use provider-plan contracts to define expectations
regarding data verification, accountability measures,
and timelines.