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Provider Directory Management

Administrative Policy:
Provider Directory Management

Effective Date:
May 1, 2017

Last Revised Date:
October 11, 2019

Scope:
This policy applies to processes that ensure that accurate participating provider network information is made available to members enrolled in all of the plans and products we offer, including QHP plans and products, in a reasonable timeframe through our online Doctor & Hospital Finder and our printed provider directories.

This policy applies to demographic information pertaining to newly contracted or credentialed physicians, other healthcare professionals, facilities and ancillary providers as well as changes to the demographic information pertaining to existing participating physicians, other healthcare professionals, facilities and ancillary providers.

Purpose:
This policy documents the processes and procedures we have in place to ensure that accurate participating provider network data is made available to members enrolled in the plans we offer through the Doctor & Hospital Finder and printed provider directories. This policy also helps ensure that the contents of the directories are fully compliant with all regulatory and accrediting requirements.

Policy:
Horizon Healthcare Services Inc., Horizon Healthcare of New Jersey, Inc. (Commercial) and Horizon NJ Health (HNJH), hereinafter collectively "Horizon BCBSNJ" will comply with all accreditation requirements, applicable laws, regulations and other communications from Federal and State regulatory bodies and accrediting agencies as described in the “Reference” Section of this policy.

Directory Requirements
The Doctor & Hospital Finder and printed directories will contain the following fields for each provider as required by CMS, DOBI and NCQA:

  • Name and professional designation.
  • Address: address1 and address2 will be listed on two lines.
  • City, State, zip.
  • Phone number.
  • Fax number.
  • Gender.
  • Specialty.
  • Hospital affiliations.
  • Group affiliations.
  • Board Certification.
  • Accepting new patients.
  • Practice limitations (Commercial only).
  • Languages spoken at the office other than English.
  • Participating networks.
  • Tier status (Commercial only).
  • Wheelchair access (HNJH only)
  • Special Needs (HNJH only)
  • A listing of the carrier’s in-network hospital outpatient facilities by the types of services the facilities provide and a statement urging members to confirm that outpatient providers practicing in network hospitals are participating.
  • Hospital accreditation.
  • Hospital quality data from a recognized source.

The electronic directories will be published in a JavaScript Object Notation (JSON) Format, also known as a machine readable format.

Printed directories will also include:

  • Date of publication.
  • Statement that the directory was accurate as of the date it was submitted for publication.
  • A statement that more current directory information is available on the carrier’s electronic directory available on the carrier’s website.
  • The anticipated date on which the next printed edition will be published.
  • The carrier’s website address where the electronic directory can be accessed.

Electronic directories will also include search functionality to allow members to customize their provider search, including but not limited to, specialty and geographic area.

Availability of Printed Directories and Web Based Provider Directory Information Through Alternate Media
Members are notified annually of the availability of the information in our Doctor & Hospital Finder and are provided with a reply card to request a printed directory.

Horizon BCBSNJ will provide print on demand directories upon request. Provider demographic information will be sent to the contracted vendor on a monthly basis or more frequently as required. The vendor will create print on demand directories upon request from members, prospective members, network providers and/or internal departments. Print on demand directories will be based on a geo-access radius from the requester’s zip code as follows:

  • 10 miles for PCPs and ObGyns
  • 25 miles for specialists and ancillary providers

The geo-access radius can be customized or a complete provider directory can be printed upon request.

Customer Service Representatives can provide information found in our Doctor & Hospital Finder via the telephone, print and mail a subset of the Doctor & Hospital Finder, or mail a printed copy of the entire directory.

Requests to Change Provider Directory Content via Electronic Media
If Horizon BCBSNJ receives feedback regarding the content of our Doctor & Hospital Finder, we will research and update our files as needed.

Horizon BCBSNJ will respond in writing within 15 days of receipt of the inquiry disputing the accuracy of the provider information.

Marketplace Transparency
Horizon BCBSNJ is committed to providing transparent information regarding the selection of physicians, other healthcare professionals, facilities and ancillary providers into networks that utilize tiering and/or a subset of an existing Horizon Network.

Provider Directory Retention

  • Horizon BCBSNJ will maintain a history of the electronic directories for three years. This requirement may be met by establishing a capability of reconstructing a directory as of any date within the prior three years.
  • Horizon BCBSNJ will retain as business records copies of each version of its printed provider directory for at least three years from the publication date.

Procedures:
Procedure for Creating a New Provider Directory File

  1. A new Hospital/Ancillary/Professional initiates/submits a request to become a Horizon BCBSNJ participating provider.
  2. The appropriate Contracting/Credentialing Department ensures that all required information is received to allow the contracting/credentialing team to conduct a complete review of the submitted information.
  3. The Credentialing Department creates a file within the appropriate internal system containing the demographic information pertaining to that Hospital/Ancillary/Professional.
  4. The Hospital/Ancillary/Professional information submitted is reviewed by our Credentialing Committee and a determination is made to accept or deny the request for participation.
  5. Following the Credentialing Committee approval of a particular Hospital/Ancillary/Professional, the provider files are updated to reflect a participating status.
  6. Once the file is completed, Hospital/Ancillary/Professional demographic information feeds automatically to the Doctor & Hospital Finder. New Hospital/Ancillary/Professional information is displayed within the Doctor & Hospital Finder within 24 to 48 hours.

Procedure for Existing Hospital/ Ancillary/ Professional Provider Directory Maintenance

  1. A participating Hospital/Ancillary/Professional initiates a request to change/update demographic information displayed the Doctor & Hospital Finder. Requests may be initiated via our online Demographic Update tool, by completing and submitting a copy of our File Change Request Form, or by submitting a letter on the practice’s or facilities letterhead.
  2. Upon receipt of the request, the appropriate department validates or makes the requested changes to the Hospital/Ancillary/Professional record in the appropriate provider files location/system within 20 days of receipt of request.
  3. Once changes are completed and reviewed for accuracy, the appropriate files department saves the updates made.
  4. Updated Hospital/Ancillary/Professional demographic information feeds automatically to the Doctor & Hospital Finder and is displayed within 24 to 48 hours.

Procedure for Delegated Physician Groups

  1. Horizon BCBSNJ does not credential physicians in delegated groups.
  2. Some delegated groups are NCQA accredited and have signed agreements to follow Horizon BCBSNJ credentialing administrative policy.
  3. Horizon BCBSNJ accepts directory maintenance files to update demographic information and participation status of practitioners.

Procedure to Ensure Accuracy of Provider Directories

  1. Physicians and other healthcare professionals that cannot be validated through NPPES will be contacted by phone to verify demographic information on a quarterly basis. Inaccurate and/or missing information identified is corrected in the provider files location/system and downloaded to our Doctor & Hospital Finder for update as outlined in the section, Procedure for Creating a New Provider Directory File of this document.
  2. On a quarterly basis, a Network Outreach Specialist will call practice locations to validate practice’s information. Three attempts will be made to contact the practitioner in that quarter. If after the third attempt Horizon in unsuccessful to validate the information the practice will be suppressed from our Online Doctor & Hospital Finder. Horizon BCBSNJ will not display any practitioner information within our Online Doctor & Hospital Finder that are unable to be validated.
  3. Practitioners may be unsuppressed by contacting Horizon BCBSNJ and requesting that Provider Data Management validate demographic information by calling the practice location directly.
  4. Practitioners may be terminated from participation if validation is not received within 180 days after suppression.

Procedure to Ensure Accuracy of Medicare Advantage Provider Directories

  1. The Provider Data Management Department conducts a quarterly physician outreach.
  2. The physician data elements that are verified are:
  • Name and professional designation.
  • Address: address1 and address2 will be listed on two lines.
  • City, State, zip.
  • Phone number.
  • Fax number.
  • Gender.
  • Specialty.
  • Hospital affiliations.
  • Group affiliations.
  • Board Certification.
  • Accepting new patients.
  • Practice limitations (Commercial only).
  • Languages spoken at the office other than English.
  1. The online Doctor & Hospital Finder and on demand hardcopy provider directories are updated no greater than every 30 days.
  2. The physician record attestation date is equivalent to the outreach date.
  3. Horizon BCBSNJ conducts a monthly audit on updated records.

State Spot Check – Practitioners in the Medicaid and FIDE-SNP Networks only PCPs, Ob/Gyns and Specialists – Demographic changes and location terminations identified by the Provider Data Management Outreach Team will be reported to the Division of Medical Assistance and Health Services (DMAHS) by the 15th of each month.

Dental Providers –Scion Dental aka SKYGEN USA is contracted by Horizon NJ Health to conduct outreach and provide results monthly in the required format that is reported to DMAHS by the 15th of each month.

References:
CMS QHP Network Adequacy 45 CFR 156.230
CMS Managed Care Manual 110.2 Provider Directory
Online Provider Directory Features (OLI Document)
NCQA – Current Standards and Guidelines for the Accreditation of Health Plans
Managed Care Network Provider Regulations 11:24C-4.5
Provider Data Management Outreach and Audit Program
Division of Medical Assistance and Health Services (DMAHS)

HCM-PP-HCS-023-0820