Accurate and up-to-date provider directories are critical for health plans and their members to ensure access to care is both reliable and efficient. For health plans, compliance with CMS’s latest guidance for provider directories is not just a regulatory requirement but also an important factor in improving member satisfaction, reducing administrative burden, and facilitating better health outcomes. For members, easily finding accurate information and available providers and services can significantly enhance their healthcare experience – and streamlined solutions help members overcome barriers to accessing care.
The Centers for Medicare & Medicaid Services (CMS) has recently released a State Health Official (SHO) letter, providing guidance on requirements and expectations for compliance with Section 5123 of the Consolidated Appropriations Act of 2023, entitled “Requiring Accurate, Updated, and Searchable Provider Directories.” State Medicaid and CHIP FFS programs as well as MCOs, PIHPs, PAHPs, and, when appropriate, PCCM entities must have updates in place to comply with these new requirements by July 1, 2025.
This letter specifically addresses:
- Data in Provider Directories: Requirement updates and features resulting from Section 5123 of the CAA, 2023
- Availability of enhanced federal financial participation (FFP) for Medicaid fee-for-service Provider Directory development and operations
- Non-Compliance: Corrective action plan requirements for reapproval of Medicaid Systems
- Process for returning to compliance and requesting reapproval of Medicaid Systems
Here’s a closer look at the key provider directory requirements that health plans must meet by the July 2025 deadline:
Updates to Medicaid and CHIP Provider Directory Requirements
- Changes the update frequency from an annual to a quarterly basis for FFS programs and primary care case management systems and adds a statutory requirement for managed care programs to update electronic Network Provider directories at least quarterly or more frequently as required by the Secretary
- Additional minimum required information and other changes for what needs to be included in the Provider Directory
- Accommodations made by the provider’s office or facility for individuals with physical disabilities
- Internet website of such provider, if applicable
- Whether the provider offers covered services via telehealth
- Whether the provider is accepting new Medicaid or CHIP patients
- Specific provider types that must be in the directory
Provider Directory API
This latest guidance also provides requirements on establishing and sustaining a publicly accessible, standards-based (HL7 FHIR Release 4.0.1) API that publishes complete and accurate Provider Directory information, including timelines for when information needs to be published in the API.
How mPulse Can Support Health Plans
mPulse delivers comprehensive solutions to meet the latest compliance requirements, offering advanced tools for provider search, data accuracy, and API integration to ensure seamless, and up-to-date member experiences. mPulse’s technology is currently compliant with the latest requirements issued in Section 5123 of the CAA, 2023.
Consumer Provider Search
Our provider directory solution is designed to turn complex network and compliance requirements into a user-friendly provider search experience for members using a wide variety of search criteria, while meeting federal and state regulations. We offer both public and secure experiences for members, and have complex plans, network, and tier support.
Provider Data Accuracy
To ensure our directories stay up-to-date, we routinely have provider attestation cycles through our provider portal, so providers can verify their information ins our system is complete and accurate. We also have a system in place for public inaccuracy reporting.
Provider Directory API
Our Provider Directory API maps existing data to FHIR and meets current standard requirements in place by CMS. mPulse’s Interoperability team is also dedicated to ensuring our API continues to meet future standard requirements, taking the burden of compliance off your team.
If you are impacted by the latest guidance released by CMS, please contact mPulse to learn how we can help support you and ensure you stay compliant by the July 2025 deadline.
