Network Adequacy & Directory Monitor
Tests the contracted network against access criteria county by county and keeps the published directory reconciled to the roster of record.
A network can clear every access criterion in the county and still send a member to a doctor who left. A rural hospital serving 60 days' notice flips four specialty types to fail; the flips, the failed ZIP codes and the self-notification window get named. Directory listings run the other loop, suppressed when an address has no billing in eighteen months and no one answers. The HSD upload and the accuracy attestation are the signing officers' to commit.
Authority
Monitor and intervene
Team role
Monitors and escalates
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Provider Network, Quality & Risk Adjustment
Desk workflow
Contract and credential the provider, load the roster, test the network against access criteria and reconcile the directory back to it, carry the measurement year through audit into submission, and put encounter and chart-review data through independent coding challenge before the officer who certifies it signs.
Collaboration
Passes a defined work product to the next owner
Decision boundary
Monitors continuously and intervenes only within stated limits.
Systems and capabilities involved
Quest Enterprise Services
Adequacy testing and provider data integrity against the contracted roster.
HPMS Network Management Module
Reads Automated Criteria Check results and the failed-county ZIP report; the upload itself is committed by the designated officer.
CMS Provider Supply file
The available-supply denominator any exception request has to argue against.
BetterDoctor Provider Portal
Outbound verification to the practice and the record of what came back.
Claims history by address and TIN
Billing signal used to corroborate that a listed location is real.
Handoffs
What this role gives and receives
Capabilities offered
County adequacy re-test
Re-runs time-and-distance, minimum-count and beneficiary-coverage criteria for named counties against the current roster.
- Receives:
- Roster of record, county set, specialty types, and the HSD reference criteria in force
- Returns:
- Pass or fail per specialty per county, the failed-ZIP list, and the contracting targets that would clear each failure
Delegates
Price what it would take to contract the supply that clears a failing county. Trigger: A specialty type fails the criteria in a county where the Provider Supply file shows available providers. Returns: Costed target list by provider, with the unit-cost effect of each addition.
Handoff to
Receives from
Receives from
External handoff
CMS Account Manager
External handoff
Network Compliance Officer
External handoff
Provider Data Management
Context
What the role needs to do the work
- Current work
- Roster of record in force, pass or fail per specialty per county, open failed-ZIP lists, verification attempts outstanding, and suppression state per listing.
- Prior interactions
- Prior triennial and off-cycle reviews, past terminations and the flips they caused, and each verification cycle's response history by practice.
- Policies and reference
- Time-and-distance and minimum-count criteria by county type, telehealth-credit eligibility, QHP provider access and appointment wait standards, and the state matrix.
- Working method
- Suppression and labeling policy, the self-notification runbook, and the evidence pattern an exception request has to carry.
Illustrative workflow
How the work moves
Starting point
A 220-bed hospital in a rural county serves notice of a without-cause termination effective in 60 days.
- 01
Pull every roster row under that TIN, including the employed groups and each practice address rolled up to it, and re-run the affected counties against the criteria in force.
- 02
Report which specialty types flip and which ZIP codes land in the failed-county report, separating flips caused by this termination from failures already open.
- 03
Assemble the self-notification package for the CMS Account Manager and hand the failing specialties to contracting as a target list.
- 04
Queue the directory listings tied to the TIN for suppression on the termination date and mark the members whose continuity-of-care notice is triggered.
Result
A failed-county file with the flips, the supporting evidence and a drafted self-notification, held for the Network Compliance Officer who submits in HPMS.
Checks and boundaries
What must be tested or reviewed
- 01No unverified listing is ever recorded as verified, and no HSD upload, exception filing or annual accuracy attestation is executed here.
- 02Reproduces the Automated Criteria Check on a held-out county set: pass or fail per specialty, the failed-ZIP list, the 90 percent coverage floor in large metro and metro counties against 85 percent in micro, rural and CEAC counties, and the ten-point telehealth credit applied only to the eligible specialty types.
- 03A hospital termination injected mid-run must surface every specialty and county that flips as a consequence, and must leave alone the counties where the remaining network still clears.
- 04Directory suppression is scored both ways: listings with no billing from the address and no verification response get labeled, and a practice that bills weekly but ignores the portal stays published.
Human authority
- The Network Compliance Officer commits HSD submissions and exception requests in HPMS.
- A designated C-suite officer signs the annual directory accuracy attestation under 42 CFR 422.111(m)(4).
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