(a) A health carrier shall post electronically a current and accurate provider directory for each of the carrier’s network plans with the information and search functions described in paragraphs (3) and (4) and:
Terms Used In Hawaii Revised Statutes 431:26-105
carrier: includes an accident and health or sickness insurer that issues health benefit plans under part I of article 10A of this chapter, a mutual benefit society under article 1 of chapter 432, and a health maintenance organization under chapter 432D. See Hawaii Revised Statutes 431:26-101
Contract: A legal written agreement that becomes binding when signed.
Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan, offered or administered by a person or entity, including but not limited to an insurer governed by this chapter, a mutual benefit society governed by article 1 of chapter 432, and as a health maintenance organization governed by chapter 432D. See Hawaii Revised Statutes 431:26-101
Facility: means an institution providing health care services or a health care setting, including hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, urgent care centers, diagnostic facilities, laboratories, and imaging centers, and rehabilitation and other therapeutic health settings licensed or certified by the department of health under chapter 321. See Hawaii Revised Statutes 431:26-101
Health care professional: means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with the practitioner's scope of practice under state law. See Hawaii Revised Statutes 431:26-101
Network: means the group or groups of participating providers providing services under a network plan. See Hawaii Revised Statutes 431:26-101
Network plan: means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use, health care providers managed, owned, under contract with, or employed by the health carrier. See Hawaii Revised Statutes 431:26-101
Person: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. See Hawaii Revised Statutes 431:26-101
Tier: means specific groups of providers and facilities identified by a network and to which different provider reimbursement, covered person cost-sharing, provider access requirements, or any combination thereof, apply for the same services. See Hawaii Revised Statutes 431:26-101
(1) The health carrier shall ensure that the general public is able to view all current providers for a plan through an identifiable link or tab and without creating or accessing an account or entering a policy or contract number;(2) The health carrier shall update each network plan provider directory at least monthly and shall periodically audit a reasonable sample size of its provider directories for accuracy and retain documentation of such an audit to be made available to the commissioner upon request;(3) For each network plan, the health carrier shall make available the following information in a searchable format:
(A) For health care professionals:
(i) Name;(ii) Gender;(iii) Participating office locations;(iv) Specialty, if applicable;(v) Medical group affiliations, if applicable;(vi)Facility affiliations, if applicable;(vii) Participating facility affiliations, if applicable;(viii) Languages spoken other than English, if applicable; and(ix) Whether accepting new patients;(B) For hospitals:
(i) Hospital name;(ii) Hospital type, such as acute, rehabilitation, children’s, or cancer;(iii) Participating hospital location; and(iv) Hospital accreditation status; and(C) For facilities, other than hospitals, by type:
(i) Facility name;(ii) Facility type;(iii) Type of services performed; and(iv) Participating facility locations; and(4) In addition to the information in paragraph (3), a health carrier shall make available the following information for each network plan:
(A) For health care professionals:
(i) Contact information;(ii) Board certifications; and(iii) Languages spoken other than English by clinical staff, if applicable; and(B) For hospitals and facilities other than hospitals: telephone number.(b) Upon the request of a covered person or prospective covered person, a health carrier shall provide a print copy of a current provider directory or of the requested directory information as follows:
(1) The following provider directory information for the applicable network plan shall be included:
(A) For health care professionals:
(i) Contact information;(ii) Participating office locations;(iii) Specialty, if applicable;(iv) Languages spoken other than English, if applicable; and(v) Whether accepting new patients;(B) For hospitals:
(i) Hospital name;(ii) Hospital type, such as acute, rehabilitation, children’s, or cancer; and(iii) Participating hospital location and telephone number; and(C) For facilities, other than hospitals, by type:
(i) Facility name;(ii) Facility type;(iii) Types of services performed; and(iv) Participating facility locations and telephone number; and(2) The health carrier shall include a disclosure in the provider directory that the information in paragraph (1) included in the directory is accurate as of the date of printing and that covered persons or prospective covered persons should consult the carrier’s electronic provider directory on its website or call customer service to obtain current directory information.(c) For electronic and print provider directories, a health carrier shall indicate the following information:
(1) For each network plan:
(A) A description of the criteria the carrier has used to build the carrier’s provider network;(B) If applicable, a description of the criteria the carrier has used to tier providers;(C) If applicable, the method by which the carrier designates the different provider tiers or levels in the network and identifies, for each specific provider, hospital, or other type of facility in the network, the tier in which each is placed, such as by name, symbols, or grouping, so that a covered person or prospective covered person may identify the provider tier; and(D) If applicable, that authorization or referral may be required to access some providers;(2) The provider directory applicable to a network plan, such as inclusion of the specific name of the network plan as marketed and issued in this State; and(3) A customer service electronic mail address and telephone number or electronic link that covered persons or the general public may use to notify the health carrier of inaccurate provider directory information.(d) For the information required by subsections (a)(3), (a)(4), and (b)(1) in a provider directory pertaining to a health care professional, hospital, or facility other than a hospital, the health carrier shall make available through electronic and print provider directories the source of the information and any limitations, if applicable.(e) The electronic and print provider directories shall accommodate the communication needs of individuals with disabilities and include a link to or information regarding available assistance for persons with limited English proficiency.
