1. (a)

   1. (1) A list of provider types developed by the State Insurance Department and the Department of Health will be monitored for network adequacy.
   2. (2) The provider types are defined in terms of National Uniform Claim Committee taxonomy codes.

   3. (3) The provider type list will be reviewed annually for:

      1. (A)

2. (i) Sufficiency.

   1. (ii) This could be to add provider types deemed necessary for coverage of healthcare services most appropriate for Arkansans or to remove provider types that are no longer appropriate; and

      1. (B)

         1. (i) Definitions.
         2. (ii) This is to ensure that the taxonomies associated with the provider type conveys the intended scope of the provider type.
         3. (iii)
3. (a) (a) The taxonomy association with a provider type definition communicates the actual practice of the provider rather than their academic qualification.
4. (b) (b) For example, a provider qualified as an internal medicine physician cannot be considered a primary care provider if the provider works only in emergency rooms or is only associated with a pain management clinic.

5. (b)

   1. (1) The State Insurance Department will facilitate a system of ongoing industry data maintenance of NPI associations with various provider types defined in subsection (a) of this section.
   2. (2) This association will be based on the provider's actual practice.
   3. (3) This will be done to facilitate a common and uniform understanding of each provider's provider type or types classification.
   4. (3) This NPI association data with provider types will be referred to as Provider Type NPI Pool (PTNP) data.
   5. (4) The process and timelines in the PTNP data maintenance effort will be outlined by the State Insurance Department on an annual basis through online documentation.

   6. (5)

      1. (A) The process will involve two (2) stages of data submission by the carriers.
      2. (B) The first stage will involve suggestions of changes in the PTNP followed by the second stage when the carriers will vote on the suggestions consolidated from the first stage.

   7. (6) The State Insurance Department will facilitate oversight of the process and may classify an NPI lacking unanimous agreement among carriers.

      1. (c) Participation exemptions.
   8. (1) A carrier with fewer than five thousand (5,000) covered individuals as of December 31 of the previous calendar year will not be required to participate in the PTNP data maintenance process.
   9. (2) For purposes of determining whether a carrier is subject to the participation requirements of PTNP data maintenance the carrier must aggregate the number of covered individuals for all companies at the Group Code level as defined by the National Association of Insurance Commissioners.
   10. (3) Carriers that offer medical, dental, and pharmaceutical benefits, or any combination thereof, under separate or combined plans will count all covered individuals, irrespective of the comprehensiveness of the plan, toward the five thousand (5,000) covered individuals threshold.
   11. (4) If a carrier does not believe it meets the definition of a submitting entity herein or does not believe it meets the five thousand (5,000) covered individuals threshold, that entity may dispute the Insurance Commissioner's decision in accordance with the Arkansas Administrative Procedure Act, Arkansas Code § 25-15-201 et seq.

Codification Notes: “NPI” means National Provider Identifier.