Last Updated: Jan 16, 2020
In its latest Provider News update, Highmark reminded providers who participate in its network to verify their directory information. Highmark says that providers who do not validate their data on a quarterly basis will be removed from the directory and their status within Highmark’s networks may be affected.
The Centers for Medicare and Medicaid Services requires Highmark to reach out to providers to confirm the following:
- The provider name is correct – Ensure a physician’s name in the directory matches the name on his/her medical license.
- The practice name is correct – CMS asks that the name listed within the provider directory match the office name that is stated when phones are answered to assist patients.
- The provider’s specialties are correctly listed – Make sure all specialties currently being practiced by each clinician are listed.
- There are not providers listed at practice locations where they don’t actually practice – Clinicians listed in the directory must be affiliated with the group and accept appointments and see patients at the location on a regular basis.
- The provider is accepting new patients, or not accepting new patients, at the location – Highmark asks providers to keep Patient Acceptance Panels updated on a quarterly basis.
- The provider’s street address and phone/fax numbers are correct – Making even small changes such as suite number changes are necessary to remain in compliance.
If you need to make updates to your directory data, you can do so using the “Provider File Management” option available in Navinet.
Highmark will be conducting outreach telephone calls to verify provider data.
More Ways to Ensure Your Provider Data Is Accurate
Practices are encouraged to proactively verify the items noted above on a regular basis with any insurers they work with. That includes notifying insurers regarding significant changes, such as when a clinician retires or leaves the practice.
Make sure you are making regular updates via CAQH’s Proview database every 120 days. Since many health plans use this database for credentialing, provider directories, and other administrative processes, this helps ensure the organizations you work with have access to accurate information about you. Find CAQH ProView resources and updates here.
Practices and clinicians who provide services through Medical Assistance, Pennsylvania’s Medicaid program, can update their information via the PROMISe system.
Beginning in January 2020, the National Plan and Provider Enumeration System (NPPES) will allow physicians and other health care providers to certify their National Provider Identifier (NPI) data. This effort on behalf of the Centers for Medicare & Medicaid Services (CMS) is to enhance Medicare beneficiaries’ ability to locate participating providers to determine access to care, as well as encourage Medicare Advantage organization provider directory accuracy. Provider information can be certified using the National Plan and Provider Enumeration System (NPPES) here.