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19-540 Timely Provider Data Verification Reminders

Date: 06/28/19

Timely Provider Demographic Data Validation Reminder

Accurate provider information allows for timely access to care

Outdated provider information can create barriers to timely access to care for members. Contracting providers must keep their office information current to ensure California Health & Wellness Plan (CHWP) members have access to accurate information for scheduling appointments and in selecting providers.

You may receive calls from CHWP or a regulator regarding the status of your contract as well as other demographic information. It is important that an administrator or member of your team who is familiar with the provider’s contract details responds to these inquiries. Any request from CHWP or a regulator should be responded to in a timely manner.

Notification and maintenance requirements

Providers directly contracting with CHWP must notify CHWP of changes by completing the online form or by reaching out to their Provider Relations representative. The online form is available on the provider website at www.CAHealthWellness.com under Provider > Resources > Provider Data Reporting. CHWP contracts with LexisNexis^® Risk Solutions, in partnership with the American Medical Association, to outreach and validate demographic information twice a year. Practitioners that receive a request from LexisNexis via email, fax or phone, should respond timely to their request. A response is required to avoid being removed from the plan’s provider directory.

LexisNexis is only utilized for directly contracted relationships. If you receive a request and you do not manage the practitioner’s direct contract, you need to reply to LexisNexis advising that you do not manage the direct contract relationship and provide the correct contact responsible for the direct contract. Do not direct LexisNexis to an independent practice association (IPA) contact as the validation is specific to the practitioner’s direct contract with CHWP.

IPAs, hospitals and ancillary providers may also receive an email, fax or phone call once a year, at a minimum, requesting that they validate their demographics. Response is required in most cases to avoid being removed from the plan’s provider directory.

As stated in the Provider Participation Agreement (PPA), providers are required to provide a minimum of 30 days advance notice of any changes to their demographic information. If the change pertains to the status of accepting new patients, the provider must notify CHWP or the applicable IPA within five business days.

Providers contracting through an IPA must notify the IPA directly of changes, and the IPA notifies CHWP. IPAs must have policies in place that establish and implement processes to collect, maintain and submit their provider demographic changes to CHWP on a real-time basis. Real time is within 30 days, as defined by the Centers for Medicare & Medicaid Services (CMS). The plan conducts random audits of IPAs to validate processes and policies to ensure they are maintaining provider demographic information on a regular basis.