Reminder: Provider directory update requirements

It's time to remind you that CMS and NCQA requires health plans to connect with provider offices no less than quarterly to confirm each provider's demographic information for the provider directory. Currently, we're asking providers to review their demographic information display on the Find a Doctor tool and submit changes as necessary (see below). Additionally, CAQH reminds providers to review and update their provider directory information via the CAQH's Direct Assure® Provider Directory solution quarterly.

Other touchpoints

We currently have several provider communication touchpoints that you should be aware of that will help us to maintain compliance with regulatory bodies:

  • Random provider directory audit calls to provider offices are being conducted to validate our information and help educate providers on the regulatory requirements.
  • Providers requesting address changes will be asked to validate which addresses should be displayed on the Provider directory. Addresses identified where a member cannot call to make an appointment with the provider will not be displayed on our provider directory. These addresses will be maintained in our systems as a "coverage location" for billing purposes only.
  • Priority Health uses the CAQH application as our source of truth upon initial credentialing. Providers are required to review and update their CAQH information and attest to the accuracy of the data every 90 days. Your CAQH Provider Profile and our provider directory information will be reviewed for accuracy and compared to the information received from your office during random provider directory audit calls.

Priority Health's Provider Directory, Find a Doctor, is the way in which our members, future members and referring medical practitioners find you! Do we have your practice information correct? Please review your information.

Provider directory requirements

Provider directory regulatory bodies, including Medicare, Medicaid and NCQA, require health plans to communicate at least quarterly with providers and hospitals to ensure the accuracy of the provider directory information. Providers must review the following:

  • Name
  • Gender
  • Specialty
  • Hospital affiliation
  • Medical group affiliation
  • Board certification
  • Accepting new patients (PCP only)
  • Languages spoken (by provider and staff)
  • Office location and phone number
  • Office hours
  • Provider website address
  • Accessibility for people with disabilities
  • Cultural competency training

If your Find a Doctor directory information is not correct, please:

Submit changes to your provider information to PH-PELC@priorityhealth.com using a Provider Change Form, other preapproved format, or, for delegated entities, updates can be made through the monthly file submission process. We need at least 60 days' notice for all provider information changes. This allows for adequate time for data validation and updating of our systems. Keeping your information up–to-date assures that members can reach you in a timely manner and your payments can reach you without delay.

Compliance

Health Plans are subject to severe financial penalties for misinformation displayed on their provider directory. As a result, providers who fail to timely notify Priority Health of changes to their information may be subject to future financial penalties and/or may be terminated from the network. For a retirement or termination from your group practice, 90-days advanced notice is required. These requirements can be found in our Provider Center, under our credentialing page

New solutions are being explored

It is our desire to help our providers reduce administrative burden while maintaining an accurate provider directory for our members, which will allow them to make informed decisions regarding their care. We are looking into new processes and technological solutions to allow providers to easily manage their provider directory data.