Frequently Asked Questions
Who is eligible for the Incorrect Provider Directory Cost-Sharing Limit?
Applies when a participant receives services from a nonparticipating provider after being informed by the plan's directory or response protocol that the provider was in-network.
How does the Incorrect Provider Directory Cost-Sharing Limit work?
Limits cost-sharing to in-network levels if a taxpayer relies on inaccurate provider directory information that incorrectly listed a provider as participating.
What law authorizes the Incorrect Provider Directory Cost-Sharing Limit?
The Incorrect Provider Directory Cost-Sharing Limit is authorized under IRC §9820 of the Internal Revenue Code (Title 26, United States Code).
Statutory Text — IRC §9820
Source: Internal Revenue Code, Title 26, United States Code
§ 9820. Protecting patients and improving the accuracy of provider directory information(a) Provider directory information requirements(1) In generalFor plan years beginning on or after January 1, 2022, each group health plan shall—(A) establish the verification process described in paragraph (2);
(B) establish the response protocol described in paragraph (3);
(C) establish the database described in paragraph (4); and
(D) include in any directory (other than the database described in subparagraph (C)) containing provider directory information with respect to such plan the information described in paragraph (5).
(2) Verification processThe verification process described in this paragraph is, with respect to a group health plan, a process—(A) under which, not less frequently than once every 90 days, such plan verifies and updates the provider directory information included on the database described in paragraph (4) of such plan or issuer of each health care provider and health care facility included in such database;
(B) that establishes a procedure for the removal of such a provider or facility with respect to which such plan or issuer has been unable to verify such information during a period specified by the plan or issuer; and
(C) that provides for the update of such database within 2 business days of such plan or issuer receiving from such a provider or facility information pursuant to section 2799B–9 of the Public Health Service Act.
(3) Response protocolThe response protocol described in this paragraph is, in the case of an individual enrolled under a group health plan who requests information through a telephone call or electronic, web-based, or Internet-based means on whether a health care provider or health care facility has a contractual relationship to furnish items and services under such plan, a protocol under which such plan or such issuer (as applicable), in the case such request is made through a telephone call—(A) responds to such individual as soon as practicable and in no case later than 1 business day after such call is received, through a written electronic or print (as requested by such individual) communication; and
(B) retains such communication in such individual’s file for at least 2 years following such response.
(4) DatabaseThe database described in this paragraph is, with respect to a group health plan, a database on the public website of such plan or issuer that contains—(A) a list of each health care provider and health care facility with which such plan or such issuer has a direct or indirect contractual relationship for furnishing items and services under such plan; and
(B) provider directory information with respect to each such provider and facility.
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