A provider directory is the list your insurance company publishes of every doctor, hospital, clinic, lab, and pharmacy in a plan's network. It's the tool you're expected to use to check whether your providers are covered before you enroll.
It's also frequently wrong. Federal audits have repeatedly found significant error rates in Marketplace directories: doctors listed who left the network, providers shown at addresses they no longer practice at, and specialists listed as accepting new patients when they aren't.
Insurers are required to update directories regularly and to correct errors when notified, but the practical burden of verification still lands on you.
How to use a directory without getting burned:
If you were given incorrect directory information and end up with an out-of-network bill, you have grounds to appeal. Many states require the insurer to cover the service at your in-network rate when a directory error caused the mistake. Documentation of what the directory said, and when, is what makes that appeal work.
We verify provider lists directly with carriers before enrolling clients rather than relying on directory listings. Call (305) 330-1277 if you'd like your providers checked.
File an appeal with your insurer, including a screenshot or dated record of the directory listing. Many states require the plan to honor your in-network cost share when a directory error caused the error, and the No Surprises Act may also apply depending on the circumstances.
Continuously. Providers join and leave networks throughout the year, and networks are rebuilt annually at renewal. Re-verify your providers every Open Enrollment even if nothing about your plan appears to have changed.
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