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The changing healthcare landscape brings new market realities: a wider range of consumer choices, lower-cost health plans with narrow provider networks, and limited knowledge among providers and patients about the specific insurance products in which they participate. Inaccuracies in provider directories can result in patients unknowingly accessing out-of-network providers or being unable to find where an in-network provider is located.

To address consumer concerns, the federal government, states and other regulatory bodies are issuing new regulations to ensure provider directories are current and accurate.

The one-to-many solution enables providers to update a specific subset of their information required for provider directories within the CAQH Provider Data Portal. That information can then be shared with all participating health plans which providers authorize to receive their information. This process eliminates the need for outreach to providers from every plan with which they contract.

Beginning in December 2015, CAQH started emailing quarterly reminders to healthcare providers on behalf of participating health plans to review their directory information. The email asks providers to log in to the CAQH Provider Data Portal, review their provider directory information, make any necessary updates and then confirm that this information can be published. Those who do not respond to email are also contacted by phone. The confirmation is time stamped, and a snapshot of the information is taken for audit purposes.

Directory confirmation integrates with the regular CAQH Provider Data Portal attestation process that providers are familiar with for credentialing purposes, making the experience seamless.

Directory confirmation integrates with the regular CAQH Provider Data Portal attestation process. Providers are now able to both update their health plan directory information and re-attest to all their CAQH Provider Data Portal professional information concurrently. Providers who complete the required attestation steps upon receipt of the quarterly email will, in fact, be re-attesting to their data every 90 days.

However, should providers not follow this 90-day schedule to update their provider data, they are still required to attest to their data profiles every 120 days (every 180 days for IL providers) to comply with credentialing requirements. If providers do not attest within the required timeframe, their CAQH Provider Data Portal status will be changed to Expired.

Participating health plans have access to the Outreach Compliance Report, an auditable record of provider outreach performed by CAQH. CAQH reports on all active providers on a participating health plan’s directory roster who have completed attestation in CAQH Provider Data Portal, a record of all provider-facing communications, and the outcomes of those communications. This report is provided in ASCII or Excel format and available on the sFTP server.

The report includes:

• Provider Identifiers (Name, CAQH Provider ID, Type 1 NPI)
• Directory Confirmation Date
• Recipient Email Address
• Email Timestamp
• Phone Number Called
• Phone Call Timestamp
• Phone Call Outcome

Yes. Health plans need to submit and maintain separate roster files for provider directory and all other uses, including credentialing. The provider directory file requires a specific format. Please contact your CAQH account manager to obtain access to the roster file specifications.

Providers submitted on a provider directory roster do not need to have an existing CAQH Provider Data Portal account or already be included on a traditional CAQH Provider Data Portal roster. CAQH sends new providers a welcome email inviting them to join CAQH Provider Data Portal to create, update and maintain their directory information.

Yes, the system has been designed for different sets of providers, to allow for cases in which a plan must outreach to providers whom they are not credentialing.

CAQH can assist in transforming a current return roster into directory roster. After the initial directory roster submission, you will have to submit the same additions and removals to both rosters.

Yes. A provider directory return roster is sent to organizations participating in CAQH Directory Management.

A provider directory extract is available to health plans that participate. This data extract contains any confirmed and attested information for all providers on an organization’s provider directory roster. Data extracts include only those providers who have attested since the last extract was received. A summary file is included in the extract to identify what directory information has changed since the last attestation.

CAQH Coordination of Benefits streamlines benefit coordination for health plans, providers and patients. Timely and accurate COB information produced by CAQH COB increases efficiency and helps to reduce:

• Administrative costs
• Inaccurate payments
• Member and provider call volumes
• Claim rework
• Dependency on overpayment and recovery vendors

CAQH COB can be used by many types of health organizations:

• Health Plans
• State Sponsored Programs
• Clearinghouses