Division of Insurance Information Sessions on Carrier Provider Directory Information to Identify a Provider’s Availability for Patients

Insured health plans are expected to comply with certain provider directory requirements, including those identified in M.G.L. c. 176O, 211 CMR 52.00 and Filing Guidance Notice 2024-H.  During information sessions held earlier this year, questions were raised about a section of the Filing Guidance Notice 2024-H, which states the following:

whether the Health Care Provider is:  is available to accept new patients covered by the Carrier; 2. is not accepting new patients covered by the Carrier; or 3. has limited availability to accept new patients covered by the Carrier with a waitlist of 4 weeks or less to schedule an appointment.

The Division has taken into account that federal agencies are developing standards associated with availability standards. The comments the Division has received about forthcoming federal guidance, along with the difficulty in collecting reliable availability information from providers, have led to the Division’s decision at this time to delay the implementation of specific provisions identified in 211 CMR 52.15(h)1-3.  The Division expects to revisit the requirements of this subsection in future filing guidance materials.

At this time, the Division expects that Carriers should develop a check-off box where the Health Care Provider should check “yes” or “no” to the following questions:

“Are you accepting new patients?”  if the answer is yes, “Are you able to contact the new patient to schedule an appointment within 4 weeks?”

When later presenting this information in Provider directories, Carriers should include language directing patients to call the Health Care Provider for the most accurate information regarding appointment availability and to learn about other Health Care Provider types, including nurse practitioners or physician assistants, that may be available within the Health Care Provider’s practice.

At this time, as the majority of the provider directory changes identified in Filing Guidance Notice 2024-H have been implemented, the Division has scheduled time on the following dates to explore the best constructive guidance to address provider availability:

Wednesday, May 27 from 1-2 and 6-7       Carriers present their credentialing and contracting processes

Wednesday, June 10 from 1-2 and 6-7           Providers react to credentialing and contracting processes

Wednesday, June 24 from 1-2 and 6-7           Consider options that might streamline processes

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