NO SURPRISES ACT

PROVIDER DIRECTORY VERIFICATION REQUIREMENTS

Under the No Surprises Act, health plans must establish a provider data verification process to ensure that the information they provide in their online provider directory is accurate, up-to-date and easy to access.

Print directories must include the last update date and direct consumers to the online database to confirm provider participation.

A publicly accessible response protocol database that contains accurate information about to ensure accurate network status of in-network providers and facilities.

VERIFICATION

REQUIREMENTS

JANUARY 1, 2022

Plans must establish a provider directory verification process & establish a procedure for removing providers or facilities with unverifiable information. Not less than once every 90 days, plans must verify and update their provider directory database. Plans will be required to update their directory database within 2 business days of receiving a provider update. Plans must respond to consumer provider directory telephone calls within one business day of receiving a request.

INFORMATION TO VERIFY

• NAME
• ADDRESS
• SPECIALTY
• TELEPHONE NUMBER
• DIGITAL CONTACT INFORMATION

ProTip: Enhance your customer experience and take your provider data verification process one step further by adding these fields:

• Individual NPI
• Organizational Tax Identification Number (TaxID or TIN)
• Group NPI
• Accepting New Patients (Y/N)
• Published in the Directory (Y/N)

HOW TO COMPLY WITH GOOD FAITH, REASONABLE INTERPRETATION

Health plans must have a documented, defendable process to show their efforts to comply with the provider directory verification requirements. What should this process include? We have the answer! Follow this workflow to create your defendable process.

PROVIDER DIRECTORY Providers who verified data as required, and with NO "RED FLAGS" RELATED TO CONSUMER ACCESS.

PROVIDER DIRECTORY Providers who verify data DATA INSPECTION REVEALS CONCERNS as required, but the data inspection reveals concerns about access. As an example, a provider verifies to practice at 20 locations. The provider gets added to the directory because the verification requirements have been met. However, given that 20 locations are a high number of locations for a single provider, the provider is flagged as needing to improve the quality of the information.

Providers who do not verify data REMOVED FROM PROVIDER DIRECTORY in the required timeframe are removed from the directory.

ProTip: After removing these providers, further research them to find out if they are seeing patients. For example, if you see evidence that indicates the provider is currently active, you’ll want to have the provider verify the requested information. Once verified, you can restore the provider to the directory.

Provider is active and outreach leads to verification.

Provider is no longer active and should be permanently removed.

SAVE TIME, STAY COMPLIANT WITH QUEST ANALYTICS

With Quest Enterprise Services, you gain the tools you need to establish a provider data verification process that’s right for your business. Whether you're looking for a quick snapshot of the latest changes in your data, needing to take a deep dive into provider information or wanting an easier way to make strategic decisions about your network, we have you covered.

COMPLIANCE MONITORING
AUTOMATED ACTIONABLE ANALYTICS
PROVIDER DATA MANAGEMENT
PROJECT OVERSIGHT & GUIDANCE
NETWORK MODELING ACCURACY
API PROVIDER IMPACT ANALYSIS
VOLUME ACTIONS

And our clients benefit from our team partnership. We do the heavy lifting of data management, outreach and analysis so that you can spend your time focusing on what really matters: making sure your provider directory is ready for prime time!