Provider Directory Regulations: A State-by-State Guide

Provider directories have long been a source of inaccurate provider information. As a result, federal (CMS) and state regulations will be enforced to ensure that healthcare consumers receive accurate information. Failure to comply with these specific state regulations will result in certain penalties.

Stemming from work with health plans throughout the United States, our compliance team compiled a list of regulations for each state.

State Regulations

State	Regulation	Health Plan	Link to Official Content
Arkansas	Must update directories every 14 days	All	Click here
California	Must update online directories weekly	All	Click here
Colorado	Must update directories monthly	QHP	Click here
Connecticut	Must update directories annually	MCO	Click here
Delaware	Must update online directories annually	QHP	Click here
Florida	Must update online directories semi-annually	EPO	Click here
Georgia	Must update online directories every 30 days	MCO	Click here
Idaho	Must update directories monthly	QHP	Click here
Louisiana	Must update directories annually	All	Click here
Maryland	Must update online directories every 15 days	All	Click here
Montana	Must update directories annually	QHP	Click here
Nevada	Must update directories every 30 days	QHP	Click here
New Jersey	Must update online directories every 10 days	MCO	Click here
New York	Must update online directories every 15 days	HMO	Click here
North Carolina	Must update directories annually	All	Click here
Oregon	Must update online directories monthly	MCO – Workers Comp	Click here
Tennessee	Must update directories annually	MCO	Click here
Texas	Must update directories quarterly	EPO, HMO, PPO	Click here
Vermont	Must update directories semi-annually	MCO	Click here
Washington	Must update directories monthly	All	Click here (Subchapter B)
Wisconsin	Must update directories annually	HMO	Click here

Beyond the proposed timeline of updates, states have also released their expectations for provider directory content. If you would like to learn more about these specific requirements please contact us.

No State Regulation

Where there are no state requirements, the following CMS guidelines must be followed: Provider directories must contain relevant and accurate provider information. This will be implemented through directory maintenance through monthly updates of provider information and quarterly touch points with providers within a Qualified Health Plan network.

State Name	Regulation	Health Plans	Link to appropriate CMS letter
Alabama, Alaska, Arizona, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Mexico, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, Utah, Virginia, West Virginia, Wyoming	Must update provider directories monthly and collect up-to-date information from providers quarterly	QHP & Medicare Medicaid	Guidance to Verify that Networks are Adequate and Provider Directories are Current (p. 134-135)

With the recent demand for transparency in healthcare, specifically in provider data, CMS federal regulations have been put in place to promote efficiency within the healthcare system. State regulations have begun to fall in line with this nationwide agenda. Thus, it is clear that no state is free of regulations pertaining to provider directories, and most states are aligning themselves with federal regulations.

Explanation of Acronyms
MCO – Managed Care Organization: Health plans that provide health care in return for a monthly fee and coordinate care through a defined network of physicians and hospitals. Examples of this include HMOs, PPOs and EPOs.
HMO – Health Maintenance Organization: Under this plan, enrollees have one primary care physician and need a referral before they can see any other healthcare professional, except in an emergency.
PPO – Preferred Provider Organization: Enrollees can go to any healthcare professional without a referral inside or outside a health plan’s network.
EPO – Exclusive Provider Organization: Enrollees have a limited network of doctors and hospitals to choose from, which is set by a health plan. It is important for enrollees to know who participates in their plan’s network
QHP – Qualified Health Plan: Designation given to health plans that are sold in the marketplace under the Affordable Care Act (ACA)