Provider directories: keeping them accurate.
Employees pick plans and doctors based on the provider directory. Federal rules require plans to keep that information current, which makes it worth knowing who does the work.
What the rules expect.
Verification Cycle
Plans must verify provider directory information at least every 90 days. Employers should ask the carrier or administrator how this cycle works in practice and who confirms it. Keep any written response with plan records, and ask counsel how the rule applies to your plan.
What Must Be Listed
A directory must include provider names, addresses, specialty, phone and digital contact details. Employers can spot-check a few listings against what employees tell them. If details are missing or look wrong, report it to the carrier or administrator and keep a record of the exchange.
Why It Matters
Employees rely on the directory when choosing care, so errors can lead to unexpected out-of-network bills. A wrong listing can lead to a surprise bill and an upset employee. HR can reduce risk by telling employees to confirm network status directly with the plan before scheduling care.
The clocks that apply to a plan’s directory.
Every 90 Days
The plan must verify and update its provider directory information at least once every 90 days, and it must have a process for removing providers it cannot verify. Ask how providers that cannot be verified are handled and how quickly they are removed. A written description of the process shows the plan has a method and not just a promise.
2 Business Days
When a provider or facility sends updated information, the plan must update its directory database within 2 business days. Employers should ask how provider updates are received, logged and posted. A quick turnaround helps employees see correct information, especially when a provider leaves the network or changes locations.
1 Business Day
If a participant calls to ask whether a provider is in network, the plan must respond in writing within 1 business day of the call. Staff who take employee questions should know the plan has a process for written responses. Share the phone number and keep a copy of any written reply an employee receives.
In-Network Cost Sharing
If a participant relied on inaccurate network information and then saw an out-of-network provider, the plan cannot charge more than the in-network cost sharing amount, and the care counts toward in-network deductible and out-of-pocket limits. Employees should keep proof of what they relied on, such as screenshots or call notes. Employers should direct questions to the carrier or administrator and ask counsel about disputed cases.
Public Website
The plan must keep a database of its contracted providers and facilities on a public website, with the directory information for each one. Employers can check the directory themselves to see whether it is easy to find and use. Confirm the link is included in enrollment materials so employees know where to look.
Who Handles It
For insured plans the carrier usually runs the directory. Self-funded plans typically rely on the administrator, so it is worth confirming that in writing. Responsibility can differ by plan, so check each one. A short written confirmation from the carrier or administrator makes it clear who maintains the directory and who answers questions.
Source: 42 U.S.C. 300gg-115, and the parallel provisions in the Internal Revenue Code and ERISA.
What plan sponsors can do.
Confirm Who Maintains It
Ask the carrier or administrator how the directory is verified and how often it is updated. Ask for the answer in writing, including the date of the last verification and how errors are corrected. File it with other plan records and revisit it at renewal.
Give Employees A Path To Report Errors
Tell members where to report a wrong listing and what to keep when they rely on one. Include a phone number or web form in enrollment materials and on the intranet. Encourage employees to save screenshots, names and call details if they rely on a listing.
Keep It In Open Enrollment
Remind employees to check network status with the plan before scheduling care. Add a short reminder to enrollment guides and meeting slides. Tell employees to confirm network status before scheduling, especially for specialists, imaging, surgery and other higher-cost services. A repeat reminder at hire also helps new employees.
Three questions to settle.
How Often Is It Verified
Ask for the process and the date of the last update. Ask the carrier or administrator to describe the process and the dates of recent updates. If answers are vague, ask for a written statement and raise the issue at renewal.
What Happens On A Bad Listing
Ask how the plan treats a member who relied on wrong directory information. Ask for the plan’s written process for members who relied on bad information, including how claims are reprocessed. Share a plain-language version with employees, and ask counsel about unresolved disputes.
Who Answers Member Questions
Name the contact for network questions. Give employees one number and one email for network questions, and make sure HR knows the same contact. Review the contact each year to confirm it still works. Post the contact on your benefits intranet page too.
Common Questions About Provider Directories
Who keeps the directory current?
The plan, usually through its carrier or administrator, is responsible for verification.
How often must it be verified?
At least every 90 days.
Does the employer maintain it?
Usually the carrier or administrator does. Confirm that in your agreements.
What if a listing is wrong?
The member should contact the plan promptly and keep a record of what the directory said.
Does this connect to balance billing?
Yes. Accurate networks help members avoid surprise out-of-network bills.
Is this legal advice?
No. For a specific issue, involve your counsel. We can help you organize your plan documents and questions.
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