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Accurate Provider Directories Now Mandatory

ILLINOIS’ Network Adequacy and Transparency Act had its origin at the Chicago Medical Society, after a CMS Network Adequacy Taskforce looked into the problem of narrowing health plan networks. After studying the trend, gathering testimony from patients, interviewing health plan executives and speaking with assorted experts, CMS drafted a resolution laying out the legislative basis for the eventual law. After CMS brought this measure to the Illinois State Medical Society, ISMS worked with members of the General Assembly to revise and implement what become known as the NAT Act. Here is what the legislation requires of network health insurance plans sold in the state to do:  
• Post electronically an up-to-date, accurate, and complete provider directory for each of its network plans.
• Ensure that the general public is able to view all of the current providers for a plan through a clearly identifiable link or tab and without creating or accessing an account or entering
a policy or contract number.
• Update the online provider directory at least monthly.
• Once providers notify the network plan electronically or in writing of any changes to their information as listed in the provider directory, network plans must update their online provider directory in a manner consistent with the information provided by the provider within 10 business days after being notified of the change by the provider.
• Audit periodically at least 25% of its provider directories for accuracy, make any corrections necessary, and retain documentation of the audit. The network plan shall submit the audit to the director upon request.
• As part of these audits, network plans will contact any providers in their networks who have not submitted a claim to the plan or otherwise communicated their intent to continue participation in the plans’ network.
• Provide a print copy of a current provider directory or a print copy of the requested directory information upon request of a beneficiary or a prospective beneficiary. Print copies must be updated quarterly and include any errata that reflects changes in the provider network must be updated quarterly.
• In plain language in both the electronic and print directory, plans must include the following general information: (a) the criteria the plan has used to build its provider network; (b) the criteria the insurer or network plan has used to create tiered networks; (c) a description of how the network plan designates the different provider tiers or levels in the network and identifies for each specific provider, hospital, or other type of facility in the network which tier each is placed, for example, by name, symbols, or grouping, in order for a beneficiary-covered person or a prospective beneficiary-covered person to be able to identify the provider tier; and (d) a notation that authorization or referral may be required to access some providers.

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