Department of Consumer and Business Services
Insurance Regulation - Chapter 836
Division 53
HEALTH BENEFIT PLANS
836-053-0350
Provider Directory Requirements for Network Adequacy
(1)(a) An insurer shall post electronically a current, accurate and complete provider directory for each of its network plans with the information and search functions, as described in section (2) of this rule.
(b) In making the directory available electronically, the insurer shall ensure that the general public is able to view all of the current providers for a plan through a clearly identifiable link or tab and without creating or accessing an account or entering a policy or contract number.
(c)(A) An insurer shall update each network plan provider directory at least monthly. The provider directory shall disclose the frequency with which it is updated.
(B) The insurer shall include a disclosure in the directory that the information included in the directory is accurate as of the date posted to the web or printed and that enrollees or prospective enrollees should consult the insurer to obtain current provider directory information.
(d) An insurer shall provide a print copy, or a print copy of the requested directory information, of a current provider directory with the information described in section (2) of this rule upon request of an enrollee or a prospective enrollee.
(e) For each network plan, an insurer shall include in plain language in both the electronic and print directory, the following general information:
(A) A description of the criteria the insurer has used to build its provider network;
(B) If applicable, a description of the criteria the insurer has used to tier providers;
(C) If applicable, information about how the insurer designates the different provider tiers or levels in the network and identifies for each specific provider, hospital, or other type of facility in the network which tier each is placed, for example by name, symbols or grouping, in order for an enrollee or a prospective enrollee to be able to identify the provider tier; and
(D) If applicable, note that authorization or referral may be required to access some providers.
(f)(A) An insurer shall make it clear in both its electronic and print directories which provider directory applies to which network plan, such as including the specific name of the network plan as marketed and issued in this state.
(B) The insurer shall include in both its electronic and print directories a customer service email address and telephone number or electronic link that enrollees or the general public may use to notify the insurer of inaccurate provider directory information.
(g) For the pieces of information required under this section in a provider directory pertaining to a health care professional, a hospital or a facility other than a hospital, the insurer shall make available through the directory a general explanation of the source of the information and any limitations, if applicable.
(h) A provider directory, whether in electronic or print format, shall accommodate the communication needs of individuals with disabilities, and include a link to or information regarding available assistance for persons with limited English proficiency.
(2) The insurer shall make available through an electronic provider directory that includes search functions, for each network plan, all of the following information:
(a) For health care professionals:
(A) Name;
(B) Gender;
(C) Participating office locations;
(D) Specialty, if applicable;
(E) Participating facility affiliations, if applicable;
(F) Languages spoken by provider other than English, if applicable;
(G) Whether accepting new patients;
(H) Network affiliations;
(I) Tier level, if applicable;
(J) Contact information; and
(K) Board certifications.
(b) For hospitals:
(A) Hospital name;
(B) Participating hospital location;
(C) Hospital accreditation status;
(D) Network affiliations;
(E) Tier level, if applicable; and
(F) Telephone number.
(c) For facilities, other than hospitals, by type:
(A) Facility name;
(B) Facility type;
(C) Participating facility locations;
(D) Network affiliations;
(E) Tier level, if applicable; and
(F) Telephone number.
Statutory/Other Authority: ORS 731.244 and ORS 743B.505
Statutes/Other Implemented: ORS 743B.505
History:
ID 10-2016, f. & cert. ef. 9-14-16