Sec. 2. Improving the availability and accuracy of provider directory information made available by group health plans and health insurance issuers offering group or individuals health insurance coverage

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Subpart II of part A of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg–11 et seq.) is amended by adding at the end the following new section: Beginning not later than January 1, 2022, each group health plan and health insurance issuer offering group or individual health insurance coverage shall— establish the verification process described in subsection (b); establish the response protocol described in subsection (c); establish the database described in subsection (d); and include in any directory (other than the database described in paragraph (3)) containing provider directory information with respect to such plan or such coverage the information described in subsection (e).

The verification process described in this subsection is, with respect to a group health plan or a health insurance issuer offering group or individual health insurance coverage, a process— under which such plan or such issuer (as applicable) verifies and updates the provider directory information included on the database described in subsection

(d)of such plan or issuer of— not less frequently than once every 90 days, a random sample of at least 10 percent of health care providers and health care facilities included in such database; and any such provider or such facility included in such database that has not submitted any claim to such plan or such issuer (as applicable) during a 12-month period; that establishes a procedure for the removal from such database of such a provider or facility with respect to which such plan or issuer has been unable to verify such information during a period specified by the plan or issuer; and that provides for the update of such database within 2 business days of such plan or such issuer (as applicable) receiving from such a provider or facility information pursuant to section 1150C of the Social Security Act. The response protocol described in this subsection is, in the case of an individual enrolled under a group health plan or group or individual health insurance coverage offered by a health insurance issuer who requests information through a telephone call or email on whether a health care provider or health care facility has a contractual relationship to furnish items and services under such plan or such coverage, a protocol under which such plan or such issuer (as applicable)— responds to such individual as soon as practicable, and in no case later than 1 business day after such call or email is received, through a written electronic communication; and retains such communication in such individual’s file for at least 2 years following such response. The database described in this subsection is, with respect to a group health plan or health insurance issuer offering group or individual health insurance coverage, a database on the public website of such plan or issuer that contains— a list of each health care provider and health care facility with which such plan or such issuer has a contractual relationship for furnishing items and services under such plan or such coverage; and provider directory information with respect to each such provider and facility. The information described in this subsection is, with respect to a directory containing provider directory information with respect to a group health plan or individual or group health insurance coverage offered by a health insurance issuer, a notification that such information contained in such directory was accurate as of the date of publication of such directory and that an individual enrolled under such plan or such coverage should consult the database described in subsection

(d)of such plan of— not less frequently than once every 90 days, a random sample of at least 10 percent of health care providers and health care facilities included in such database; and any such provider or such facility included in such database that has not submitted any claim to such plan during a 12-month period; that establishes a procedure for the removal from such database of such a provider or facility with respect to which such plan has been unable to verify such information during a period specified by the plan; and that provides for the update of such database within 2 business days of such plan receiving from such a provider or facility information pursuant to section 1150C of the Social Security Act. The response protocol described in this subsection is, in the case of an individual enrolled under a group health plan who requests information through a telephone call or email on whether a health care provider or health care facility has a contractual relationship to furnish items and services under such plan, a protocol under which such plan— responds to such individual as soon as practicable, and in no case later than 1 business day after such call or email is received, through a written electronic communication; and retains such communication in such individual’s file for at least 2 years following such response. The database described in this subsection is, with respect to a group health plan, a database on the public website of such plan that contains— a list of each health care provider and health care facility with which such plan has a contractual relationship for furnishing items and services under such plan; and provider directory information with respect to each such provider and facility. The information described in this subsection is, with respect to a directory containing provider directory information with respect to a group health plan, a notification that such information contained in such directory was accurate as of the date of publication of such directory and that an individual enrolled under such plan should consult the database described in subsection

(d)with respect to such plan or contact such plan to obtain the most current provider directory information with respect to such plan. For purposes of this section, the term provider directory information includes, with respect to a group health plan, the name, address, specialty, and telephone number of each health care provider or health care facility with which such plan has a contractual relationship for furnishing items and services under such plan or such coverage. . Section 9815(a) of the Internal Revenue Code of 1986 is amended— in paragraph (1), by striking (as amended by the Patient Protection and Affordable Care Act) and inserting (other than the provisions of section 2730 of such Act) ; and in paragraph (2), by inserting (other than the provisions of section 2730 of such Act) after the first occurrence of such part A . The table of sections for such subchapter is amended by adding at the end the following new items: Sec. 9815. Additional market reforms. Sec. 9816. Provider directory requirements. . Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185 et seq.) is amended by adding at the end the following new section: Beginning not later than January 1, 2022, each group health plan and health insurance issuer offering group health insurance coverage shall— establish the verification process described in subsection (b); establish the response protocol described in subsection (c); establish the database described in subsection (d); and include in any directory (other than the database described in paragraph (3)) containing provider directory information with respect to such plan or such coverage the information described in subsection (e). The verification process described in this subsection is, with respect to a group health plan or a health insurance issuer offering group health insurance coverage, a process— under which such plan or such issuer (as applicable) verifies and updates the provider directory information included on the database described in subsection

(d)of such plan or issuer of— not less frequently than once every 90 days, a random sample of at least 10 percent of health care providers and health care facilities included in such database; and any such provider or such facility included in such database that has not submitted any claim to such plan or such issuer (as applicable) during a 12-month period; that establishes a procedure for the removal from such database of such a provider or facility with respect to which such plan or issuer has been unable to verify such information during a period specified by the plan or issuer; and that provides for the update of such database within 2 business days of such plan or such issuer (as applicable) receiving from such a provider or facility information pursuant to section 1150C of the Social Security Act. The response protocol described in this subsection is, in the case of an individual enrolled under a group health plan or group health insurance coverage offered by a health insurance issuer who requests information through a telephone call or email on whether a health care provider or health care facility has a contractual relationship to furnish items and services under such plan or such coverage, a protocol under which such plan or such issuer (as applicable)— responds to such individual as soon as practicable, and in no case later than 1 business day after such call or email is received, through a written electronic communication; and retains such communication in such individual’s file for at least 2 years following such response. The database described in this subsection is, with respect to a group health plan or health insurance issuer offering group health insurance coverage, a database on the public website of such plan or issuer that contains— a list of each health care provider and health care facility with which such plan or such issuer has a contractual relationship for furnishing items and services under such plan or such coverage; and provider directory information with respect to each such provider and facility. The information described in this subsection is, with respect to a directory containing provider directory information with respect to a group health plan or group health insurance coverage offered by a health insurance issuer, a notification that such information contained in such directory was accurate as of the date of publication of such directory and that an individual enrolled under such plan or such coverage should consult the database described in subsection

(d)with respect to such plan or such coverage or contact such plan or the issuer of such coverage to obtain the most current provider directory information with respect to such plan or such coverage. For purposes of this section, the term provider directory information includes, with respect to a group health plan and a health insurance issuer offering group health insurance coverage, the name, address, specialty, and telephone number of each health care provider or health care facility with which such plan or such issuer has a contractual relationship for furnishing items and services under such plan or such coverage. . Section 715(a) of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185d(a) ) is amended— in paragraph (1), by striking (as amended by the Patient Protection and Affordable Care Act) and inserting (other than the provisions of section 2730 of such Act) ; and in paragraph (2), by inserting (other than the provisions of section 2730 of such Act) after the first occurrence of such part A . The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 is amended by inserting after the item relating to section 714 the following new items: Sec. 715. Additional market reforms. Sec. 716. Provider directory requirements. . Part A of title XI of the Social Security Act ( 42 U.S.C. 13010 et seq.) is amended by adding at the end the following new section: Beginning not later than 1 year after the date of the enactment of this section, each health care provider and health care facility shall establish a process under which such provider or facility transmits, to each health insurance issuer offering group or individual health insurance coverage and group health plan with which such provider or supplier has in effect a contractual relationship for furnishing items and services under such coverage or such plan, provider directory information (as defined in section 2730(e) of the Public Health Service Act, section 716(e) of the Employee Retirement Income Security Act of 1974, or section 9816(e) of the Internal Revenue Code of 1986, as applicable) with respect to such provider or facility, as applicable. Such provider or facility shall so transmit such information to such issuer offering such coverage or such group health plan— when there are any material changes (including a change in address, telephone number, or other contact information) to such provider directory information of the provider or facility with respect to such coverage offered by such issuer or with respect to such plan; and at any other time (including upon the request of such issuer or plan) determined appropriate by the provider, facility, or the Secretary. Each health care provider or health care facility that fails to transmit information as required under subsection

(a)shall be subject to a civil monetary penalty of $1,000 for each day such provider or facility (as applicable) fails to so transmit such information. The provisions of section 1128A (other than subsection (a), subsection (b), the first sentence of subsection (c)(1), subsection (d), and subsection (o)) shall apply with respect to a civil monetary penalty imposed under this subsection in the same manner as such provisions apply with respect to a penalty or proceeding under subsection

(a)of such section. In this section, the terms health insurance issuer , group health plan , group health insurance coverage , and individual health insurance coverage have the meaning given such terms, respectively, in section 2791 of the Public Health Service Act ( 42 U.S.C. 300gg–91 et seq.). .

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U.S. Code

3 references not yet in our index

42 USC 300gg–11
42 USC 13010
42 USC 300gg–91

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Sec. 2

Improving the availability and accuracy of provider directory information made available by group health plans and health insurance issuers offering group or individuals health insurance coverage

U.S.C.§ 1185

U.S.C.§ 1185d

Cite42 USC 300gg–11

Cite42 USC 13010

Cite42 USC 300gg–91

Cites 5Cited by 0 across 0 sources