(E) For purposes of this subdivision, “financially compensated” means having paid five
one or more claims to a provider for that
network, paid capitation, or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees insureds covered by the relevant network.
(f) The provider directory or directories shall include both an email address and a telephone number for members of the public and providers to notify the insurer if the provider directory information appears to be inaccurate. This information shall be disclosed prominently in the directory or directories and on the insurer’s internet website.
(g) The provider directory or directories shall include the following
disclosures informing insureds that they are entitled to both of the following:
(1) Language interpreter services, at no cost to the insured, including how to obtain interpretation services in accordance with Section 10133.8.
(2) Full and equal access to covered services, including insureds with disabilities as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973.
(h) The insurer and a specialized mental health insurer shall include all of the following information in the provider directory or directories:
(1) The provider’s name, practice location or locations, and contact
information, including telephone number.
(2) Type of practitioner.
(3) National Provider Identifier number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) The provider’s office email address, if available to an insured or the public.
(7) The population served, meaning adult, pediatric, or both.
(8) The name of each affiliated provider group currently under contract with the insurer through which the provider sees
insureds.
(9) A listing for each of the following providers that are under contract with the insurer:
(A) For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the insurer.
(B) Nurse practitioners, physician assistants, psychologists, acupuncturists, optometrists, dispensing optometrists and opticians, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, as defined in Section 10144.51, nurse-midwives, and dentists.
(C) For federally qualified health centers or primary care clinics, the name of the federally qualified health center or clinic.
(D) For any provider described in subparagraph (A) or (B) who is employed by a federally qualified health center or primary care clinic, and to the extent their services may be accessed and are covered through the contract with the insurer, the name of the provider, and the name of the federally qualified health center or clinic.
(E) Facilities, including, but not limited to, general acute care hospitals, skilled nursing facilities, urgent care clinics, ambulatory surgery centers, inpatient hospice, residential care facilities, and inpatient rehabilitation facilities.
(F) Pharmacies,
clinical laboratories, imaging centers, optical dispensaries,
and other facilities providing contracted health care services.
(10) The provider directory or directories may note that authorization or referral may be required to access some providers.
(11) Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 10133.8, if any, on the provider’s staff.
(12) Identification of providers who no longer accept new patients for some or all of the insurer’s products.
(13) The network tier to which the provider is assigned, if the provider is not in the lowest tier, as applicable.
Nothing in this section shall be construed to require the use of network tiers other than contract and noncontracting tiers.
(14) The provider’s contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the provider’s contract if there is a termination date.
(15) If the provider has affirmed that they offer and have provided gender-affirming services, in accordance with Section 10133.14.
(16) All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c).
(i) A vision, dental, or other specialized insurer, except for a specialized mental
health insurer, shall include all of the following information for each provider directory or directories used by the insurer for its networks:
(1) The provider’s name, practice location or locations, and contact information, including telephone number.
(2) Type of practitioner.
(3) National Provider Identifier number.
(4) California license number and type of license, if applicable.
(5) The area of specialty, including board certification, or other accreditation, if any.
(6) The provider’s office email address, if available to an insured or
the public.
(7) The population served, meaning adult, pediatric, or both.
(8) The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds.
(9) The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the insurer.
(10) The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 10133.8, if any, on the provider’s staff.
(11) Identification of providers who no longer accept new patients for some or all of the insurer’s products.
(12) The provider’s contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the provider’s contract if there is a termination date.
(13) All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(j) (1) The contract between the insurer and a provider shall include a requirement that the provider inform the insurer within five business days when either of the following occurs:
(A) The provider is not accepting new patients.
(B) If the provider had previously not accepted new patients, the provider is currently accepting new patients.
(2) If a provider who is not accepting new patients is contacted by an insured or potential insured seeking to become a new patient, the provider shall direct the insurer or potential insured to both the insurer for additional assistance in finding a provider and to the department to report any inaccuracy with the insurer’s directory or directories.
(3) If an insured or potential insured informs an insurer of a possible inaccuracy in the provider directory or directories, the insurer shall promptly
investigate and, if necessary, undertake corrective action within 30 business days to ensure the accuracy of the directory or directories.
(k) (1) On or before December 31, 2016, the department shall develop uniform provider directory standards to permit consistency in accordance with subdivision (b) and paragraph (2) of subdivision (c) and development of a multiplan directory
central utility by another entity. Those standards shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), until January 1, 2021. No more than two revisions of those standards
shall be exempt from the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) pursuant to this subdivision.
(2) In developing the standards under this subdivision, the department shall seek input from interested parties throughout the process of developing the standards and shall hold at least one public meeting. The department shall take into consideration any requirements for provider directories established by the federal Centers for Medicare and Medicaid Services and the State Department of Health Care Services.
(3) By July 31, 2017, or 12 months after the date provider directory standards are developed under this subdivision, whichever occurs later, an insurer shall use the standards
developed by the department for each product offered by the insurer.
(4) On or before January 1, 2025, the department may develop a uniform format with standardized naming conventions and other aspects for each insurer to use to request directory information from its providers.
(5) On or before January 1, 2026, the department may establish a methodology and processes to ensure accuracy of provider directories. The department shall take into account existing methods, including surveys, plan-reported information, and benchmarks or submission information from a central utility by another entity. The department may require an insurer to use a central utility or designate a central utility for those providers included in the directory. In developing the methodology under this section, the
department shall seek input from interested parties and may hold one or more public meetings. Standards developed pursuant to paragraph (4) and this paragraph shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) until January 1, 2028.
(l) (1) An insurer shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the insurer’s provider directory or directories in accordance with this section, and shall, at least annually, review and update the entire provider directory or directories for each product offered. Each calendar year the insurer shall notify all contracted providers described in subdivisions (h) and (i) as follows:
(A) For individual providers who are not affiliated with a provider group described in subparagraph (A) or (B) of paragraph (8) of subdivision (h) and providers described in subdivision (i), the insurer shall notify each provider at least once every six months.
(B) For all other providers described in subdivision (h) who are not subject to the requirements of subparagraph (A), the insurer shall notify its contracted providers to ensure that all of the providers are contacted by the insurer at least once annually.
(2) The notification shall include all of the following:
(A) The information the insurer has in its directory or directories regarding the provider or provider group, including a list of networks and products
that include the contracted provider or provider group.
(B) A statement that the failure to respond to the notification may result in a delay of payment or reimbursement of a claim pursuant to subdivision (p).
(C) Instructions on how the provider or provider group can update the information in the provider directory or directories using the online interface developed pursuant to subdivision (m).
(3) The insurer shall require an affirmative response from the provider or provider group acknowledging that the notification was received. The provider or provider group shall confirm that the information in the provider directory or directories is current and accurate or update the information required to be in the directory
or directories pursuant to this section, including whether or not the provider group is accepting new patients for each product.
(4) If the insurer does not receive an affirmative response and confirmation from the provider that the information is current and accurate or, as an alternative, updates any information required to be in the directory or directories pursuant to this section, within 30 business days, the insurer shall take no more than 15 business days to verify whether the provider’s information is correct or requires updates. The insurer shall document the receipt and outcome of each attempt to verify the information. If the insurer is unable to verify whether the provider’s information is correct or requires updates, the insurer shall notify the provider 10 business days in advance of removal that the provider will be removed from the
directory or directories. The provider shall be removed from the directory or directories at the next required update of the provider directory or directories after the 10-business-day notice period. A provider shall not be removed from the provider directory or directories if the provider responds before the end of the 10-business-day notice period. If the insurer cannot verify that the information that is required by subdivisions (h) and (i) in the listing is accurate, the provider shall be deleted and removed from the directory at the next required update. Deleted provider information shall not be used for timely access monitoring, solicitation, network adequacy reporting, including time and distance standards, or compliance with this chapter.
(5) If a provider that was previously removed from the provider directory or directories requests to be added back to the provider directory or directories, or if an insurer requests that a provider that was previously removed from the provider directory or directories be added back to the provider directory or directories, the insurer shall ensure the accuracy of the request and approve the request within 10 business days of receipt if accurate.
(5)
(6) General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4).
to (5), inclusive.
(m) An insurer shall establish policies and procedures with regard to the regular updating of its provider directory or directories, including the weekly, quarterly, and annual updates required pursuant to this section, or more frequently, if required by federal law or guidance.
(1) The policies and procedures described under this subdivision shall be submitted by an insurer annually to the department for approval and in a format described by the department.
(2) Every insurer shall ensure processes are in place to allow providers to promptly verify or submit changes to the information required to be in the directory or directories pursuant to this section. Those
processes shall, at a minimum, include an online interface for providers to submit verification or changes electronically and shall generate an acknowledgment of receipt from the insurer. Providers shall verify or submit changes to information required to be in the directory or directories pursuant to this section using the process required by the insurer.
(3) The insurer shall establish and maintain a process for insureds, potential insureds, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the insurer’s provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the insurer will accept these reports, as well as a hyperlink on the insurer’s provider directory internet website linking to a
form where the information can be reported directly to the insurer through its internet website.
(n) An insurer shall be responsible for maintaining an accurate provider directory.
(1) An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2) The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate.
(A) On January 1, 2024,
July 1, 2025, an insurer’s directories shall be at least
60-percent accurate.
(B) On or before January 1, 2025, July 1, 2026, an insurer’s directories shall be at least 80-percent accurate.
(C) On or before January 1, 2026, July 1, 2027, an insurer’s directories shall be at least 90-percent accurate.
(D) On or before January 1, 2027,
July 1, 2028, an insurer’s directories shall be at least 95-percent accurate.
(3) An insurer shall annually audit and verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). If the department develops a methodology and standards that permit the use of a central utility, and if an insurer uses the central utility for some or all of the insurer’s provider directory, the insurer shall ensure that information derived from the central utility is incorporated in the insurer’s provider directory unless the insurer can demonstrate that the information is inaccurate. The insurer using a central utility shall continue to retain responsibility for ensuring
that the requirements of this section are satisfied, including in any contract or other agreement with the central utility. The department shall develop procedures and policies on how an insurer shall conduct the audits. verifications. In addition to verifying the information required under subdivisions (h) and (i), the insurer shall do all of the following:
(A) In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for insureds in that product or network. If the provider received no compensation in the last year for that product or
network, the insurer shall remove that provider from their directory pursuant to subparagraph (D) of paragraph (2) of subdivision (e).
(B) Submit its accuracy audit reports annually Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to the department to ensure compliance with this section.
(C) Publicly post its accuracy audit
verification
reports annually on its internet website.
(4) Failure by an insurer to comply with this section, including failure to meet the required benchmarks for accuracy, shall result in an administrative penalty consistent with this section and this chapter. In determining the appropriate amount of an administrative penalty, a listing inaccuracy shall be treated as a denial of access to care for covered benefits. For purposes of determining an administrative penalty based on an inaccuracy, required accurate information shall include, but not be limited to, the provider name, address, and telephone number, whether the provider is accepting new patients, whether the provider was financially compensated by the insurer consistent with this section, and any other information as determined by the department.
(4)
(5) Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of not less than five hundred dollars ($500) per 1,000 insureds and up to five thousand dollars ($5,000) per 1,000 insureds, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of not less than one thousand dollars ($1,000) per 1,000 insureds and
up to ten thousand dollars ($10,000) per 1,000 insureds for each year following the first year that the insurer failed to meet the benchmark.
(5)The insurer shall be liable for an administrative penalty of up to one thousand dollars ($1,000) for each inaccurate listing in its directory. An inaccurate listing means a listing with at least one error in the information required under subdivision (h) or (i).
(6) When assessing administrative penalties against a health insurer, the department shall determine the appropriate penalty amount for each violation based on one or more factors as applicable.
(7) Beginning January 1, 2028, 2029, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(o) (1) This section does not prohibit an insurer from requiring its provider groups or contracting specialized health insurers to provide information to the insurer that is required by the insurer to satisfy the requirements of this section for each of the providers that contract with the provider group or
contracting specialized health insurer. This responsibility shall be specifically documented in a written contract between the insurer and the provider group or contracting specialized health insurer.
(2) If an insurer requires its contracting provider groups or contracting specialized health insurers to provide the insurer with information described in paragraph (1), the insurer shall continue to retain responsibility for ensuring that the requirements of this section are satisfied.
(3) A provider group may terminate a contract with a provider for a pattern or repeated failure of the provider to update the information required to be in the directory or directories pursuant to this section.
(4) A provider group is
not subject to the payment delay described in subdivision (q) if all of the following occurs:
(A) A provider does not respond to the provider group’s attempt to verify the provider’s information. As used in this paragraph, “verify” means to contact the provider in writing, electronically, and by telephone to confirm whether the provider’s information is correct or requires updates.
(B) The provider group documents its efforts to verify the provider’s information.
(C) The provider group reports to the insurer that the provider should be deleted from the provider group in the insurer’s provider directory or directories.
(5) Section 10133.65, known as the Health
Care Providers’ Bill of Rights, applies to any material change to a provider contract pursuant to this section.
(p) (1) Whenever an insurer receives a report indicating that information listed in its provider directory or directories is inaccurate, the insurer shall promptly investigate the reported inaccuracy and, no later than 30 business days following receipt of the report, either verify the accuracy of the information or update the information in its provider directory or directories, as applicable.
(2) When investigating a report regarding its provider directory or directories, the insurer shall, at a minimum, do the following:
(A) Contact the affected provider no later than five business days
following receipt of the report.
(B) Document the receipt and outcome of each report. The documentation shall include the provider’s name, location, and a description of the insurer’s investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C) If changes to an insurer’s provider directory or directories are required as a result of the insurer’s investigation, the changes to the online provider directory or directories shall be made no later than the next scheduled weekly update, or the update
immediately following that update, or sooner if required by federal law or regulations. For printed provider directories, the change shall be made no later than the next required update, or sooner if required by federal law or regulations.
(q) (1) Notwithstanding Sections 10123.13 and 10123.147, an insurer may delay payment or reimbursement owed to a provider or provider group for any claims payment made to a provider or provider group for up to one calendar month beginning on the first day of the following month, if the provider or provider group fails to respond to the insurer’s attempts to verify the provider’s information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the provider’s or provider group’s information. As used in this subdivision,
“verify” means to contact the provider or provider group in writing, electronically, and by telephone to confirm whether the provider’s or provider group’s information is correct or requires updates. An insurer may seek to delay payment or reimbursement owed to a provider or provider group only after the 10-business-day notice period described in paragraph (4) of subdivision (l) has lapsed.
(2) An insurer shall notify the provider or provider group 10 days before it seeks to delay payment or reimbursement to a provider or provider group pursuant to this subdivision. If the insurer delays a payment or reimbursement pursuant to this subdivision, the insurer shall reimburse the full amount of any payment or reimbursement subject to delay to the provider or provider group according to either of the following timelines, as applicable:
(A) No later than three business days following the date on which the insurer receives the information required to be submitted by the provider or provider group pursuant to subdivision (l).
(B) At the end of the one-calendar-month delay described in paragraph (1), if the provider or provider group fails to provide the information required to be submitted to the insurer pursuant to subdivision (l).
(3) An insurer may terminate a contract for a pattern or repeated failure of the provider or provider group to alert the insurer to a change in the information required to be in the directory or directories pursuant to this section.
(4) An insurer that delays
payment or reimbursement under this subdivision shall document each instance a payment or reimbursement was delayed and report this information to the department in a format described by the department. This information shall be submitted along with the policies and procedures required to be submitted annually to the department pursuant to paragraph (1) of subdivision (m).
(r) (1) In circumstances where the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in an insurer’s provider
directory or directories, the department may require the insurer to insurer shall arrange care and provide coverage for all covered health care services provided to the insured and to insured, reimburse the insured for any amount beyond what the insured would have paid, had the services been delivered by an in-network provider under the insured’s health insurance policy.
policy, and reimburse the provider the contracted amount for those health care services under the policy. The provider shall not collect any additional amount from the insured other than the applicable in-network cost sharing. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the insured were covered services under the insured’s health insurance policy. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-network provider shall not be used as a basis to deny reimbursement to the insured.
(2) If an insured, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the insurer
shall, if the request is by telephone, tell the insured verbally and follow up in writing or electronic format no later than one business day after receiving the request. If the request is by electronic means, the insurer shall respond in writing or electronic format no later than one business day after receiving the request. The insurer shall also provide information on whether or not the provider is accepting new patients. The insurer shall retain a record of the request and the insurer’s response in the insured’s file for at least two years after the date of the request.
(3) For covered benefits, if an insured obtained information through the plan’s online directory or a request consistent with paragraph (2) that a provider was an in-network provider, the group insured shall pay no more than in-network cost sharing if
any of the following apply:
(A) The provider is not contracting with the insurer as an in-network provider for that product.
(B) The contracting provider is not accepting new patients for that product.
(C) The information provided is otherwise materially inaccurate, misleading, or incomplete.
(D) The online provider directory of the insurer is not accessible to insureds at the time the insured seeks information and the insured requests information consistent with paragraph (2).
(4) If the health insurance policy includes
more than one tier of cost sharing, the insurer shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the insured when the insured seeks information about the provider. If the insurer provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the insured shall owe no more than the cost sharing for the cost-sharing tier included in the information received by the insured from the insurer.
(5) For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. If the health insurance policy includes more than one tier of cost sharing and if the insured was not informed accurately of the applicable cost-sharing
tier, then the lowest cost-sharing tier shall apply.
(6) For purposes of this subdivision, “information” is inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) is inaccurate, incomplete, or misleading.
(s) (1) Whenever an insurer determines as a result of this section that there has been a 10-percent change in the network for a product in a region, the insurer shall file a statement with the commissioner.
(2) For an insurance policy issued,
amended, or renewed on or after July 1, 2025, if a provider has not been financially compensated consistent with this section or if the provider has failed to respond timely consistent with this section, and those providers amount to a change of 10 percent or greater in the network for a product in a region, then the insurer shall file an amendment to the policy application consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.
(3) An insurer shall not use information about a provider for purposes of compliance with timely access requirements, network adequacy determination, or compliance with any other provision of this chapter if the insurer cannot demonstrate to the department that the provider is contracting with the insurer and the provider has been financially compensated by the insurer consistent with this section or the provider has failed to respond timely consistent with this section.
This paragraph shall apply whether or not the provider has been deleted from the directory.
(4) Consistent with Section 1360 of the Health and Safety Code, an insurer shall not advertise or otherwise represent the extent of its network, including the number or type of contracting providers, unless it is able to demonstrate that each provider is contracting and has been compensated consistent with this section.
(t) An insurer that contracts with multiple employer welfare agreements regulated pursuant to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall meet the requirements of this section.
(u) This section shall not be construed to alter a provider’s obligation to provide health care services to an insured
pursuant to the provider’s contract with the insurer.
(v) As part of the department’s routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurer’s compliance with subdivision (q).
(w) For purposes of this section, “provider group” means a medical group, independent practice association, or other similar group of providers.