(a) Definitions. For the purposes of Health and Safety Code section 1367.27 and this Rule, the following definitions apply:
(1) “Accepting new patients” means the network provider has an open practice as set forth in subdivision (a)(4) of Health and Safety Code section 1367.035 at the reported practice address and is available to deliver care to enrollees in the network who are not currently patients, or are not assigned to the network provider, and all of the following criteria apply:
- (A) The network provider is open to enrollees in the network, including the identified product line, without limitations other than the established processes described in Rule 1300.67.2.2(b)(10).
- (B) The network provider has notified the health plan that the provider is open to new patients, and as applicable, the network provider is listed as accepting new patients in the health plan provider directory maintained pursuant to Health and Safety Code section 1367.27, for the reported practice address.
- (C) The network provider does not limit an enrollee's ability to establish patient care through only a waitlist, or other similar processes in which the provider requires a patient to wait before the patient is able to schedule an initial appointment to establish care. This provision shall not modify timely access standards set forth in subdivision (a) of Health and Safety Code section 1367.03 and Rule 1300.67.2.2(c).
- (2) “Contact information” means the phone number, hours of operation, fax number, if available, provider practice address, office email address, if available, in accordance with subdivision (d)(3) of this Rule, and website in accordance with subdivision (d)(10) of this Rule.
- (3) Unless the context of this Rule indicates otherwise, “directory” or “provider directory” means the printed and online provider directories required by Health and Safety Code section 1367.27 and this Rule. All references to “directory” or “provider directory” include all health care service plan directories required under Health and Safety Code section 1367.27 and this Rule.
- (4) “National Provider Identifier Number” or “NPI” means the number associated with a provider as registered through the National Plan and Provider Enumeration System, and as set forth in the Code of Federal Regulations, title 45, section 162.406.
- (5) “Network” shall mean the same as the definition set forth in Rule 1300.67.2.2(b)(5).
- (6) “Network identifier” means the fixed identifier assigned to each network by the Department.
- (7) “Network name” shall mean the same as the definition set forth in Rule 1300.67.2.2(b)(9).
- (8) “Policy” or “policies and procedures” means the policies and procedures required by subdivision (m) of Health and Safety Code section 1367.27 and this Rule.
- (9) “Practice address” and “practice location or locations” mean the physical location or locations where a provider delivers health care services or information as specified in subdivision (d)(6) of this Rule.
- (10) “Product” means a discrete package of health care benefits the health care service plan is licensed to offer using a particular line of business (e.g., health maintenance organization (HMO), Preferred Provider Organization (PPO), Point of Service (POS), and exclusive provider organization (EPO) within a network service area, as defined in Rule 1300.67.2.2(b)(11).
- (11) “Product line” means the combination of the health care service plan's product and the type of market segment (e.g., individual, large group, small group, government) in which the product is licensed to be offered.
- (12) “Provider” shall have the same meaning as “network provider” as defined in Rule 1300.67.2.2(b)(10).
- (13) “Provider group” and “specialty plan practice group” shall have the definition set forth in subdivision (w) of Health and Safety Code section 1367.27 and shall include “physician organization” as defined in subdivision (p) of Health and Safety Code section 127500.2.
- (14) “Provider name” means the name that appears on the provider's state license or certificate authorizing the provider to provide health care services. For providers for which licensure or certification is not required, “provider name” means the name used by the provider to deliver health care services. A health care service plan may use a doing business as (DBA) name as set forth in subdivision (d)(7)(B).
- (15) “Provider type” shall have the meaning set forth in subdivision (h)(8)(D)(iii) of Rule 1300.67.2.2.
- (16) “Restricted health care service plan” shall mean the same as the definition set forth in Rule 1300.49.
- (17) “Telehealth provider”, for purposes of this Rule, does not mean third-party corporate telehealth provider as defined in Health and Safety Code section 1374.141, unless the third-party corporate telehealth provider meets the definition of a provider as set forth in subdivision (a)(12) of this Rule.
(b) Directory Updating.
- (1) A health care service plan shall update its provider directory or directories pursuant to subdivision (m) of Health and Safety Code section 1367.27. The policies and procedures of the health care service plan shall demonstrate the health care service plan performs provider directory updates in accordance with the requirements of Health and Safety Code section 1367.27 and this Rule.
- (2) Every printed provider directory shall contain the date of the most recent update of the provider directory performed pursuant to subdivision (d) of Health and Safety Code section 1367.27. The health care service plan shall make available to the public for download on its website the most recent printed provider directory.
- (3) The health care service plan shall maintain an archive of previous versions of the provider directories for a period of five years. The health care service plan may maintain archived versions electronically, in paper, or in another format that is effective for the health care service plan and is consistent with Rule 1300.85.1. “Previous versions” means the previous versions of the provider directory made available to enrollees, potential enrollees, providers and the public by the health care service plan. For purposes of this subdivision (b)(3), the “previous version” is the version that is updated pursuant to section 1367.27 of the Health and Safety Code. For purposes of this subdivision (b)(3), a health care service plan may watermark the provider directory as “ARCHIVED” or provide a disclaimer in bold font on top of the archived provider directory stating: “This provider directory is not current and the information contained in this provider directory may be outdated and no longer applicable.”
- (4) Every online provider directory shall display the date of the most recent update performed pursuant to subdivision (e) of Health and Safety Code section 1367.27. If a health care service plan maintains a website with a link to the provider directory, the link shall be prominently displayed and labeled, “Provider Directory” or “Find a Provider”. Health care service plans shall ensure any links to a provider directory for health care service plans under the Department's authority are Knox-Keene Act compliant.
- (5) For each provider listed pursuant to subdivisions (h) or (i) of Health and Safety Code section 1367.27, the provider directory shall include the following sentence: “This information was last verified or updated on [mm/dd/yy].” This sentence shall be in the same size and font as the provider listing. The date last verified or updated shall be the date the information was last verified or updated by the health care service plan pursuant to subdivisions (l), (m)(2), or (o), whichever date is most recent, of Health and Safety Code section 1367.27. For purposes of this subdivision (b)(5), “last verified” shall mean the last time a provider verified the information in writing, electronically, or by telephone to confirm whether the provider's information is correct or requires updates.
(6) A health care service plan shall treat information it receives regarding possible inaccurate, incomplete, or misleading information currently listed in the health care service plan's provider directory or directories as a reported inaccuracy for investigation pursuant to subdivision (o) of Health and Safety Code section 1367.27. A health care service plan shall document investigations of reported inaccuracies pursuant to subdivision (o) of Health and Safety Code section 1367.27 and this Rule. The documentation shall include the frequency of inaccuracies reported to the health care service plan and the changes made to the health care service plan's directory.
- (A) Information that a health care service plan shall treat as a reported inaccuracy pursuant to this subdivision (b)(6) includes information obtained from reports of possible inaccuracies submitted to the plan via (1) the designated telephone number, email address, and online form required by subdivision (m)(3) of Health and Safety Code section 1367.27 and described in subdivision (f)(2)(G), (2) any complaints regarding provider access or availability received through a plan's customer service department or grievance system, and (3) provider data obtained through proactive internal data reconciliation among plan, delegate, and other contracted entity departments that handle provider data, including claims, contracting, networks, and provider directories.
- (B) Reports of inaccuracy submitted by an enrollee, a representative designated by the enrollee, or other individual with authority to act on behalf of the enrollee, through the health plan's customer service or grievance system shall be treated as an expression of dissatisfaction pursuant to subdivision (a)(1) of Rule 1300.68 and resolved pursuant to Health and Safety Code section 1368.
- (7) If a health care service plan receives information regarding possible inaccurate, incomplete, or misleading provider information in a network or timely access submission reviewed by the Department pursuant to Rules 1300.51 and 1300.67.2.2, the health care service plan shall treat this information as a report of inaccuracy pursuant to subdivision (o) of Health and Safety Code section 1367.27. Nothing in this subdivision relieves a health care service plan from its responsibility to update its provider directory pursuant to this Rule.
- (8) If, upon completion of an investigation as set forth in subdivision (o) of Health and Safety Code section 1367.27, a health care service plan confirms information in its provider directory is inaccurate, incomplete, or misleading, the health care service plan shall ensure that any subsequent network reports or exhibits submitted to the Department, pursuant to Rules 1300.51 and 1300.67.2.2, do not contain the inaccurate, incomplete, or misleading information.
(c) Product and Network Identification.
- (1) A health care service plan shall establish policies and procedures for providing and maintaining the provider directory or directories for the specific network offered for each product as required by subdivision (b) of Health and Safety Code section 1367.27. Each provider directory shall identify the provider network available for each health care service plan product offered. Product and Network names shall be displayed consistently in all the health care service plan's enrollee and provider communications, identification cards, and disclosures. Enrollee identification cards shall identify the health care service plan product and network names consistent with this subdivision (c)(1) of the Rule. The product and network identification contained in the provider directory shall be consistent with the information that is displayed on the enrollee's identification card.
- (2) For every product a health care service plan offers, the product name shall be distinguishable from an existing product name.
- (3) The provider directory for each health care service plan network shall display the network name and network identifier as reported to the Department pursuant to Rules 1300.51 or 1300.67.2.2, or as modified pursuant to Rule 1300.52.1.
- (4) The provider directory for each health care service plan network shall include the following statement: “The health care service plan that maintains this provider directory is regulated by the Department of Managed Health Care. If you have any questions or concerns with this directory, you can contact [name of plan] at [plan consumer phone number] or [plan consumer email address], or you can contact the Help Center with the Department of Managed Health Care at (888) 466-2219 and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department's internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.” This statement shall be displayed prominently near the beginning of the printed provider directory, and the statement shall be displayed on the main page or home page of the health care service plan online directory. This statement shall be in at least 12-point font. This statement is in addition to any statement required by subdivision (a)(4) of Health and Safety Code section 1367.042. The requirement under this subdivision (c)(4) of this Rule shall be translated in all threshold languages and made accessible to people with disabilities as required under the Knox-Keene Act, including Health and Safety Code section 1367.042 and this Rule.
(d) Provider Listings and Information.
- (1) A health care service plan provider directory shall display provider information as required by subdivisions (h) and (i) of Health and Safety Code section 1367.27, and this Rule.
- (2) For providers, including facilities, contracted with health care service plans for a limited purpose(s), a provider directory shall include information specifying the limited purpose(s) to provide clarity to the public, potential enrollees, enrollees, and providers. For the purposes of this subdivision (d)(2), of the Rule, “limited purpose(s)” means a provider is only available in emergency situations, makes rounds at a facility but their services cannot be specifically requested, is not available for office visits, is not accessible via established in-network referral or authorization processes, or other purpose(s) that limits or precludes an enrollee from obtaining health care services from a provider. In addition to specifying the limited purpose(s), the health care service plan's provider directory shall also display the words: “This provider is available for a limited purpose only” in a font size no smaller than 12-point font.
- (3) A provider directory shall include a provider's office email address only with the written permission of the provider or provider group, and only if the provider has verified the email address is intended for patient communication, and is regularly monitored. A general practice or provider group email address may also be used if it meets the requirements of this subdivision (d)(3) of the Rule.
- (4) In addition to displaying a provider's name as listed on the provider's license, a health care service plan provider directory may also include a provider's preferred name, if the health care service plan provider directory allows searching by both the provider's name as licensed and the provider's preferred name. If a provider supplies a preferred name to the health care service plan, the provider's preferred name and the provider's name as listed on the provider's license both shall be included in the online provider directory and in any copy of a printed provider directory provided pursuant to subdivision (d) of Health and Safety Code section 1367.27 and this Rule.
- (5) For each provider listing, the health care service plan provider directory shall display the NPI of the provider. For entities, including hospitals and provider groups, multiple NPIs may be listed by the health care service plan. All information shall be consistent with information reported to the Department pursuant to Rule 1300.67.2.2.
- (6) For formatting purposes, practice addresses and practice locations shall be listed consistent with United States Postal Service conventions, as provided by United States Postal Service Publication 28, Postal Addressing Standards, dated October 2024, which is hereby incorporated by reference. If the provider delivers health care services only in a patient's home or only via telehealth, or both, in place of the practice address the provider directory shall state, as applicable: “No address -- provider sees patients only in their homes;” or, “No address -- provider sees patients only via telehealth;” or, “No address -- provider sees patients only in their homes or via telehealth.” If a provider, such as a doula, delivers health care services only in the location where the patient receives health care services, only via telehealth, or both, in place of the practice address the provider directory shall state, as applicable: “No address-provider sees patients only at the location where the patient receives health care services”; or, “No address-provider sees patients only via telehealth”; or, “No address-provider sees patients only at the location where the patient receives health care services or via telehealth”.
(7) Provider groups and specialty plan practice groups shall be identified in the provider directory by the health care service plan by one of the following:
- (A) The name filed with the Department as a risk-bearing organization or as a capitated provider group or,
- (B) The provider group's or specialty practice group's business name registered with the California Secretary of State if the provider group or specialty practice group has not registered with the Department as a risk-bearing organization or is not on file with the Department as a capitated provider. The provider group or specialty practice group may use a doing business as (DBA) name if the DBA name is registered with the California Secretary of State.
- (8) Information regarding a provider's specialty shall be displayed consistent with the Department's standardized provider type terminology, pursuant to subdivision (h)(8)(D)(iii) of Rule 1300.67.2.2 of this title. Where applicable, specialty shall be reported consistent with the specialty or specialties for which the provider is contracted with the health care service plan or provider group, and with certifications issued by the American Board of Medical Specialties, specialty information associated with the provider's NPI, or the accrediting organization as identified in the provider directory. The provider directory shall identify the accrediting organization the provider directory uses to display certifications pursuant to this subdivision (d)(8) of the Rule. The accrediting organization may be listed by the health care service plan in a separate section of the provider directory. A provider that does not have a specialty identified in subdivision (h)(8)(D)(iii) of Rule 1300.67.2.2, does not need to include a specialty pursuant to this subdivision (d)(8) of the Rule.
(9) An online provider directory may incorporate a hyperlink to another provider directory to display providers available to the health care service plan's enrollees, including providers available through a specialized health care service plan or provider group.
- (A) For any provider directory incorporated by hyperlink, the health care service plan shall specify the network and the product(s) to which the hyperlink applies immediately preceding the hyperlink. The hyperlink shall be displayed prominently, in a font size no smaller than 12-point font and shall link to the intended provider directory. The hyperlink shall link the public directly to the applicable provider directory for the network name and product that is displayed on the health care service plan's hyperlink. The health plan shall contain a written warning next to the hyperlink that notifies the enrollee that by clicking the link the enrollee is accessing a different provider directory and should contact the plan to ensure that the providers listed in the hyperlink are part of the enrollee's network.
- (B) A health care service plan may incorporate hyperlinks only to provider directories that satisfy the requirements of this Rule and Health and Safety Code section 1367.27.
(10) Provider directories shall include the following information:
- (A) Link to the provider's office website, the provider group's website, or the facility's website, pursuant to Health and Safety Code section 1367.27, if the provider's office, the provider group, or the facility maintains a public website. Print provider directories do not need to display links to a provider's office website, a provider group's website, or a facility's website;
- (B) A notification to enrollees that the enrollee or the enrollee's representative may obtain a previous version of the provider directory. The notification shall state that the health care service plan only maintains previous versions of the provider directory for the last five years. The health care service plan shall provide a telephone number and/or an email address where the enrollee or the enrollee's representative may call to request a previous version of the provider directory;
- (C) Whether the provider delivers health care services at a physical location and also delivers health care services via telehealth, or whether the provider exclusively delivers health care services via telehealth, if applicable;
- (D) Whether the provider's office/facility offers (1) accommodations for persons with disabilities, including auxiliary aids and services for ensuring effective communication in-person and via telehealth; and (2) description of accommodations available to people with physical disabilities; and
- (E) How an enrollee may obtain language assistance from the health care service plan at no cost, including language assistance during telehealth appointments, consistent with Health and Safety Code sections 1367.27, 1367.03, and 1367.04, and Rules 1300.67.04 and 1300.67.2.2(c)(4). A health care service plan shall also provide notice that appropriate auxiliary aids and services, including qualified interpreters for individuals with disabilities and information in alternate formats, are available to enrollees with disabilities during telehealth appointments, free of charge and in a timely manner, when those aids and services are necessary to ensure an equal opportunity to participate for individuals with disabilities, consistent with Health and Safety Code sections 1367.27 and 1367.042.
- (F) Information related to appointment wait times and notice of availability of interpreter services at the time of appointment, pursuant to subdivisions (c) and (d) of Health and Safety Code section 1367.031.
- (11) A health care service plan may maintain a separate provider directory, or the health care service plan's provider directory may maintain separate listings, for providers exclusively available to provide services to enrollees via telehealth. If telehealth services are provided through a contracted telehealth provider, the health care service plan's provider directory shall list the telehealth provider as a provider group unless the provider is an individual provider. This separate directory shall comply with the requirements of this Rule and Health and Safety Code section 1367.27. If the health plan provides a hyperlink to the telehealth provider directory, the link to the telehealth directory shall be displayed prominently in a visible font size (not smaller than 12-point font), link directly to the intended telehealth provider directory, and specify the products to which the hyperlink applies. The health plan shall contain a written warning next to the hyperlink that notifies the enrollee that by clicking the link the enrollee is accessing a telehealth provider directory and should contact the plan to ensure that the providers listed in the hyperlink are part of the enrollee's network.
(12) A provider or provider group shall be omitted from a provider directory if one of the following is true:
- (A) The provider or provider group is required to be omitted pursuant to subdivision (e)(2) of Health and Safety Code section 1367.27, including when a provider has retired, is deceased, or is otherwise no longer under contract with the health care service plan; or
- (B) The provider or provider group is required to be removed from the directory pursuant to subdivision (l) of Health and Safety Code section 1367.27.
(13) A provider or provider group may be omitted from a provider directory if one of the following is true:
- (A) The health care service plan maintains on file a signed statement from the individual provider that the provider is currently enrolled in the California Secretary of State Safe at Home program, under Chapter 3.2 of Division 7 of title 1 of the California Government Code;
- (B) Upon submission of a signed statement from an individual provider to a health care service plan that the provider fears for their safety or the safety of their family due to their affiliation with a facility or due to their provision of health care services;
- (C) The provider is an individual provider contracted with a third-party provider group providing telehealth services only, as defined in subdivision (a) of the Business and Professions Code section 2290.5, to the health care service plan's enrollees. The provider directory shall include the third-party provider group; or
- (14) The health care service plan shall prominently display a hyperlink where enrollees, providers, and the public may report inaccurate, incomplete, or misleading information regarding the health care service plan's provider directory. These reports shall be investigated and documented pursuant to subdivision (b)(6) of this Rule.
(e) Directory Searches.
- (1) Online provider directories shall allow for searches using a combination of search elements provided in subdivision (e) of this Rule and in accordance with subdivision (c) of Health and Safety Code section 1367.27.
- (2) In addition to meeting search criteria set forth in subdivision (e)(1) of this Rule and subdivision (c) of Health and Safety Code section 1367.27, online provider directories shall also allow all users, including enrollees, potential enrollees, and members of the public, to select a health care service plan product and search for an individual provider, provider group, or facility to determine whether the provider, provider group, or facility is in the health care service plan network for the product.
- (3) Online provider directories shall be searchable pursuant to subdivision (c)(2) of Health and Safety Code section 1367.27, and in a manner that allows the search to be narrowed or filtered, at a minimum, by health care service plan product, city, ZIP Code, languages spoken, access for individuals with disabilities, specialty, provider group affiliation, hospital admitting privileges, facility, new patient availability and whether the provider offers services via telehealth, as applicable.
(f) Directory Policies and Procedures.
- (1) The health care service plan shall submit its policies and procedures as an Amendment pursuant to Health and Safety Code section 1352.
(2) The policies and procedures shall demonstrate the health care service plan's provider directories comply with the requirements of subdivision (m) of Health and Safety Code section 1367.27 and this Rule. The policies and procedures shall:
- (A) Identify the website URL for the health care service plan's online provider directories.
- (B) Identify all methods for requesting a printed provider directory from the health care service plan consistent with subdivision (d) of Health and Safety Code section 1367.27.
- (C) Demonstrate that the health care service plan's provider directories clearly identify each product offered by the health care service plan and the network available to enrollees of the product.
- (D) If the health care service plan has delegated some or all responsibility for maintaining provider directories to another entity, demonstrate how the health care service plan monitors the delegated entity to ensure compliance with Health and Safety Code section 1367.27 and this Rule.
- (E) Identify any service agreements used to support the health care service plan's compliance with Health and Safety Code section 1367.27 and this Rule.
- (F) Describe the steps taken by the health care service plan to ensure the accuracy of its provider directories, including how the health care service plan reviews and updates the provider directory. This includes the process for notifying providers in accordance with subdivision (l) of Health and Safety Code section 1367.27. A health care service plan shall submit detailed information specifying how the health care service plan monitors the provider directory for accuracy.
- (G) Demonstrate the health care service plan maintains a staffed or monitored telephone number, dedicated email address, and online form to report and timely investigate possible inaccurate, incomplete, or misleading provider directory information as required by subdivision (m)(3) of Health and Safety Code section 1367.27.
- (H) Describe the health care service plan's process to investigate any reported inaccuracy of provider directory information as required by subdivision (o) of Health and Safety Code section 1367.27 and subdivision (b)(6) of this Rule.
No later than April 1 of each year, a health care service plan shall file with the Department its policies and procedures.
(g) A health care service plan shall maintain records for a minimum of five years for review by the Department documenting the following:
- (1) All documentation required by subdivision (o) of Health and Safety Code section 1367.27 and this Rule.
- (2) All pending or unresolved reports or discoveries of possible inaccurate, incomplete, or misleading information in the health care service plan's provider directory. A health care service plan shall comply with subdivision (b)(6) of this Rule.
- (3) A report identifying any contracted providers or provider groups omitted from the health care service plan's provider directory pursuant to this Rule. This requirement does not apply to a provider whose name has been omitted due to safety concerns pursuant to subdivision (d)(13)(A) or (d)(13)(B) of this Rule. The health care service plan shall identify the reason for each contracted provider or provider group's omission from the health care service plan's provider directory.
- (4) The actions taken to remedy inaccuracies in the provider directory pursuant to subdivision (f)(2)(F) of this Rule.
- (h) Nothing in this Rule relieves a health care service plan from complying with provider directory provisions required by federal law and guidance.
- (i) A health care service plan shall comply with sections 1367.28 and 1363.02 of the Knox-Keene Act.
- (j) A health care service plan shall submit the information required pursuant to this Rule to the Department even if the health care service plan has delegated all or part of its obligations pursuant to Health and Safety Code section 1367.27 and this Rule to one or more entities.
- (k) Exception. A limited or restricted health care service plan, or a health care service plan not approved by the Department for the direct enrollment of enrollees and subscribers, is not required to publish and maintain a provider directory or directories pursuant to Health and Safety Code section 1367.27. The policies and procedures of these types of health care service plans shall demonstrate they provide all data and provider information necessary for compliance pursuant to Health and Safety Code section 1367.27 and this Rule for their contracted provider network(s) to each contracted health care service plan.
- (l) Review and enforcement. Failure to comply with requirements of this section, including the failure to maintain complete and accurate records and reports, failure to submit required policies and procedures, or failure to maintain, monitor, update, and correct inaccuracies in provider directories, may constitute a basis for disciplinary or enforcement action against the health care service plan. The Department may request additional information from the health care service plan as deemed necessary to complete the review of required records, reports, policies, procedures, or other information, or to carry out and complete any enforcement action. The health care service plan shall be responsible for demonstrating compliance with this Rule and the Knox-Keene Act. The Director shall have the civil, criminal, and administrative penalties available under the Knox-Keene Act, including section 1394. Nothing in this section shall be construed as limiting the Director's authority pursuant to Article 7 (commencing with section 1386) or Article 8 (commencing with section 1390) of the Knox-Keene Act.
Except as noted in subdivision (k) of this Rule, and consistent with Health and Safety Code section 1367.27 of the Knox-Keene Act, as amended, all health care service plans, including specialized health care service plans, shall comply with the requirements of Health and Safety Code section 1367.27 and this Rule. A health care service plan may also implement provider directory provisions that exceed these standards or provide more current information than the standards established by this Rule and Health and Safety Code section 1367.27.
Note: Authority cited: Sections 1343 and 1367.27, Health and Safety Code. Reference: Sections 1341, 1341.9, 1367 and 1367.27, Health and Safety Code.
History
1. New section filed 12-17-2025; operative 4-1-2026 (Register 2025, No. 51).