Utah Code § 31A-22-664 — Utah Code / Title 31A / Chapter 31A-22 / § 31A-22-664
§ 31A-22-664. Health care provider directories.
Status: in_force

(1) As used in this section: (a) "Division" means the Division of Professional Licensing created in Section 58-1-103. (b) "Exempt health care professional" means a person exempt from licensure under a title listed in Subsection 58-13-3(2)(c). (c) "Exempt mental health provider" means an individual exempt from licensure under Section 58-60-107. (d) "Health care facility" means the same as that term is defined in Section 26B-2-201. (e) "Health care professional" means the same as that term is defined in Section 58-13-3. (f) "Hospital" means a facility licensed under Title 26B, Chapter 2, Part 2, Health Care Facility Licensing and Inspection, as a general acute hospital or specialty hospital. (g) "Insurer" means the same as that term is defined in Section 31A-22-634. (h) "Mental health provider" means the same as that term is defined in Section 31A-22-658. (i) "Pharmacy" means the same as that term is defined in Section 58-17b-102. (j) "Provider" means: (i) a health care professional; (ii) an exempt health care professional; (iii) a mental health provider; (iv) an exempt mental health provider; or (v) a pharmacy. (k) "Provider directory" means a list of in-network providers for each of an insurer's health benefit plans. (l) "Telehealth services" means the same as that term is defined in Section 26B-4-704. (m) "Telemedicine services" means the same as that term is defined in Section 26B-4-704. (2) Beginning January 1, 2027, an insurer shall: (a) publish a provider directory for each of the insurer's health benefit plans; and (b) update the provider directory no less frequently than every 60 days. (3) An insurer shall ensure that, except as provided in Subsection (7): (a) a provider directory: (i) is easily and publicly accessible: (A) through a conspicuous link on the home page of the insurer's website; and (B) without requiring an individual to create an account or submit a policy or contract number; and (ii) is in a format that is searchable and downloadable; and (b) a provider may update the provider's information, including contact information and whether the provider is accepting new patients, in the provider directory: (i) electronically; (ii) on the insurer's website; and (iii) through a conspicuous link on the home page of the insurer's website. (4) A provider directory shall include: (a) in plain language: (i) a description of the criteria the insurer used to build the health benefit plan's provider network; and (ii) if applicable: (A) a description of the criteria the insurer used to tier health care providers; (B) how the health benefit plan designates health care provider tiers or levels; and (C) a notice that authorization or referral may be required to access some health care providers; and (b) contact information an insured or member of the public may use to report to the health benefit plan inaccurate information in a provider directory, which may include: (i) a phone number; (ii) an email address; or (iii) a link to a website or online reporting form. (5) In addition to the information required under Subsection (4): (a) a provider directory of health care professionals and exempt health care professionals shall include: (i) each health care professional's and exempt health care professional's: (A) name; (B) contact information, including: (I) internet address, if applicable; (II) physical address; and (III) phone number; and (C) specialty, if applicable; (ii) whether the health care professional or exempt health care professional is accepting new patients; and (iii) whether the health care professional or exempt health care professional offers telehealth services or telemedicine services; (b) a provider directory of health care facilities that are hospitals shall include each hospital's: (i) name; (ii) if the hospital is a specialty hospital, specialty type; (iii) location or locations; (iv) accreditation status; (v) phone number; and (vi) internet address, if applicable; (c) a provider directory of health care facilities other than hospitals shall include each health care facility's: (i) name; (ii) type; (iii) services provided; (iv) location or locations; (v) phone number; and (vi) internet address, if applicable; (d) a provider directory of pharmacies shall include each pharmacy's: (i) name; (ii) type; (iii) services provided, including whether the pharmacy offers mail-order or specialty pharmacy services; (iv) location or locations; (v) phone number; and (vi) internet address, if applicable; and (e) a provider directory of mental health providers and exempt mental health providers shall include: (i) each mental health provider's: (A) name; (B) contact information, including: (I) internet address, if applicable; (II) physical address; and (III) phone number; and (C) specialty, if applicable; (ii) whether the mental health provider or exempt mental health provider is accepting new patients; and (iii) whether the mental health provider or exempt mental health provider offers telehealth services or telemedicine services. (6) (a) For purposes of Subsection (5)(a)(ii), a health care professional is accepting new patients if an exempt health care professional who treats patients under the supervision of the health care professional is available to see new patients. (b) For purposes of Subsection (5)(e)(ii), a mental health provider is accepting new patients if an exempt mental health provider who treats patients under the supervision of a mental health provider is available to see new patients. (7) (a) An insurer may provide, in addition to an electronic provider directory, a provider directory in print format. (b) An insurer shall provide a provider directory in print format to an insured upon request of the insured. (c) In addition to the requirements described in Subsections (4) and (5), a provider directory in print format shall include: (i) the internet address of the insurer's website where the insurer's electronic provider directory is published; (ii) the health benefit plan's customer service phone number; (iii) a disclosure that the information in the provider directory is accurate, to the best of the insurer's knowledge, based on the information the provider provided, as of the date of printing; and (iv) a notice that an insured or prospective insured should consult the health benefit plan's electronic provider directory or call the health benefit plan's customer service phone number to obtain current provider directory information. (8) When an insurer receives a report of inaccurate information in a provider directory, the insurer shall: (a) promptly investigate the report; and (b) no later than the end of the 20th business day after the day on which the insurer receives the report: (i) verify the accuracy of the information in the provider directory; or (ii) for an electronic provider directory, update the inaccurate information with accurate information. (9) (a) An insurer shall take steps to ensure the accuracy of the information in a provider directory, including contacting providers to verify that provider information is up to date. (b) When an insurer contacts a provider to verify the accuracy of a provider's information in a provider directory, the provider shall respond to the insurer's request for verification no later than 15 business days after the day on which the insurer contacts the provider. (10) (a) An insurer shall, at least annually, audit each provider directory for accuracy. (b) (i) (A) include the two mental health specialties and four physical health specialties most utilized by insureds; and (B) include at least one specialty related to mental health; or (ii) audit a reasonable sample size of providers, if the sample size includes mental health providers. (c) An insurer shall: (i) retain documentation of each audit performed under this Subsection (10); (ii) submit the audit to the commissioner upon the commissioner's request; and (iii) based on the results of the audit: (A) verify and attest to the accuracy of the information in a provider directory; and (B) update inaccurate information in a provider directory with accurate information. (11) (a) An insurer shall report to the commissioner upon request on: (i) the number of reports of inaccuracies in provider directories the insurer received; (ii) the timeliness of the insurer's response to a report of inaccuracies in a provider directory; (iii) any corrective action the insurer took in response to a report of inaccuracies in a provider directory; (iv) the identity of providers that failed to timely respond to the insurer's request for verification as required under Subsection (9); (v) all audits the insurer conducted in accordance with this section; and (vi) any other information related to provider directory accuracy the commissioner considers relevant. (b) The commissioner may request the information described in Subsection (11)(a) no more frequently than annually. (c) (i) If an insurer finds that a provider demonstrates a repeated pattern of violations of Subsection (9), the insurer shall: (A) issue an educational letter to the provider; and (B) send a copy of the educational letter to the commissioner and the division. (ii) If an insurer notifies the commissioner that a provider demonstrates a repeated pattern of violations of Subsection (9), the commissioner shall send an educational letter to the provider. (12) An insurer, a health care facility, a hospital, or a provider that is subject to this section shall comply with all applicable requirements of the No Surprises Act, 42 U.S.C. Secs. 300gg-111 through 300gg-139, and federal regulations adopted in accordance with that act. (13) The commissioner may make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to implement the provisions of this section. (14) In addition to the penalties authorized under Section 31A-2-308, if the commissioner determines that, when an insured received services under the insured's health benefit plan, the insured reasonably relied on inaccurate information in a provider directory, the commissioner may: (a) if the commissioner determines that the insurer knew or reasonably should have known the information was inaccurate: (i) require the insurer to provide coverage for all covered health care services the insured received; and (ii) reimburse the insured for the amount the insured paid for the health care services that exceeds what the insured would have paid if the services were delivered by an in-network provider; and (b) if the commissioner determines that the provider provided inaccurate information or failed to update the information, require the insurer to reimburse the provider at the in-network rate.