Illinois Administrative Code › Title 50 - INSURANCE › Part 4540 - NETWORK ADEQUACY AND TRANSPARENCY › Section 4540.60 - Provider Directory Audits

Current through Register Vol. 48, No. 28, July 12, 2024
a) By
			 April 1 of each year, an insurer shall file with the Department a report
			 applicable to all provider directories of all its network plans that describes
			 the protocols the insurer uses to ensure that it complies with the requirements
			 in Section 25 of the Act to keep each electronic directory up-to-date,
			 accurate, and complete by updating it both at least monthly and within 10
			 business days of receipt of updated information from preferred providers, as
			 well as to update the print directory and errata quarterly and to ensure that
			 the print directory is accurate as of the date of publication. The report shall
			 also describe the insurer's current verification process established pursuant
			 to 42 U.S.C.
			 300gg-115(a)(2). The report
			 shall also describe any changes to these protocols and to the verification
			 process that have occurred since the beginning of the previous calendar year.
			 The report shall describe all variances in the protocols and the verification
			 process among the insurer's network plans or between its different provider
			 directories, including any distinctions made among HMO and Preferred Provider
			 Organization (PPO) networks. An insurer that demonstrates that, at all times
			 during the audit period, the contents of any print directory are printed from
			 the same data used for the corresponding online directory on the same date of
			 printing is exempt from auditing the print directories separately. For 2023,
			 the report shall be filed no later than July 1.
b) An insurer must conduct the periodic
			 self-audit required under Section 25(a)(3) of the Act for each provider
			 directory no less than twice per year. If an insurer has not completed a
			 self-audit for each provider directory by the date this rule takes effect, it
			 shall audit the provider directory for that network plan and generate a report
			 by July 1, 2023. The insurer's unredacted internal self-audit reports generated
			 during the previous calendar year shall be attached to the report required
			 under subsection (a).
c) Each
			 self-audit report generated on or after July 1, 2023 must include a summary
			 specifically identifying each print and electronic directory audited, the
			 marketing name of each network plan using that directory, and the SERFF
			 Tracking Number of the most current filing under Section 10 of the Act that
			 contained the directory. The summary must specify, at a minimum:
1) For each print or electronic directory
			 audited and each provider specialty type in that directory, the number of
			 preferred providers for which the self-audit revealed any incorrect provider
			 directory information at the time of audit;
2) For each print or electronic directory
			 audited and for each provider specialty type in that directory, the number of
			 preferred providers that had furnished corrected or updated information to the
			 insurer more than the following number of business days prior but the
			 self-audit revealed any incorrect provider directory information still present:
A) for an electronic directory, 10 business
			 days before the auditor reviewed that provider's directory information,
			 and
B) for a print directory that
			 is not an on-demand, unaltered printout of the electronic directory, 10
			 business days before the date of printing;
3) For each print or electronic directory
			 audited and for each provider specialty type in that directory, the number of:
A) preferred providers with directory entries
			 updated since the prior self-audit;
B) preferred providers that submitted updates
			 to their provider directory information since the prior self-audit;
			 and
C) preferred providers from
			 whom the insurer requested updated information because of the self-audit or
			 other internal detection of inaccurate information or any complaint received of
			 inaccurate provider information since the prior self-audit;
4) For each print or electronic directory
			 audited and for each provider specialty type in that directory, the smallest,
			 largest, and median number of business days since the prior self-audit between:
A) the insurer's receipt of updated
			 information from a preferred provider or the termination of a provider contract
			 if the insurer is contractually required to update the directory on its own
			 initiative; and
B) the insurer's
			 update to the electronic or print provider directory;
5) The combined totals of the numbers in
			 subsections (c)(1) through (4) across all provider specialty types, both within
			 each directory and across all directories provided by the insurer;
			 and
6) A high-level evaluation of
			 the effect of known internal or external processes or circumstances and changes
			 to those processes or circumstances on the accuracy of the insurer's
			 directories and the timeliness of updates to directory information under State
			 and federal requirements.