2016 -- H 7709

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LC004849

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2016

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A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representatives McKiernan, O'Brien, Almeida, Casey, and Bennett

     Date Introduced: February 24, 2016

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

     SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness

Insurance Policies" is hereby amended by adding thereto the following section:

     27-18-82. Health care provider credentialing. – (a) A health care entity or health plan

operating in the state shall be required to issue a decision regarding the credentialing of a health

care provider within twenty (20) calendar days of the date of receipt of a complete credentialing

application. In all cases, the health care entity or health plan must take action on the application

within ninety (90) days of receipt of the application, whether or not the application is complete.

     (1) Each health care entity or health plan shall establish a written standard defining what

elements constitute a complete credentialing application and shall distribute this standard with the

written version of the credentialing application and make such standard available on the health

care entity's or health plan's website.

     (2) The health care entity or health plan shall not consider the following when

determining if a credentialing application is complete:

     (i) Whether the health care provider has been granted medical staff privileges at a health

care facility;

     (ii) Whether the health care entity or health plan has completed an evaluation that is

entirely at the discretion of the health care entity or health plan, such as a site visit or chart

review; or

     (iii) Whether the health care entity or health plan has received letters of reference on

behalf of the health care provider.

     (b) Each health care entity or health plan shall establish a database on its website to

update health care providers regarding the status of each health care provider's credentialing

application and listing any items required before the health care entity or health plan will deem

the credentialing application complete. The database shall be updated within seven (7) calendar

days of the date of receipt of any items related to a health care provider's credentialing application

and within seven (7) calendar days of any change to a health care provider's credentialing status.

     (c)(l) If the health care entity or health plan denies a credentialing application, the health

care entity or health plan shall notify the health care provider in writing within twenty (20)

calendar days from the date of receipt of the credentialing application and shall provide the health

care provider with any and all reasons for denying the credentialing application and what if any

additional information is required to complete the credentialing application.

     (2) If a credentialing application is denied due to a health care provider's failure to

provide one or more items needed for a complete credentialing application, the health care

provider shall have an opportunity to appeal such denial, upon written request to the health care

entity or health plan within twenty (20) days of denial. which request shall include any missing

credentialing application items or documentation establishing that such items were previously

delivered to the health care entity or health plan. The health care entity or health plan shall render

a decision on the appeal within ten (10) days of the date of receipt of the health care provider's

written request.

     (d) The effective date for billing privileges for health care providers under a particular

health care entity or health plan shall be the later of the date of the receipt by the health care

entity or health plan of a complete credentialing application that was subsequently approved by

the health care entity or health plan, or the date the health care provider is licensed by the Rhode

Island department of health.

     (e) For the purposes of this section, the following definitions apply:

     (1) "Date of receipt" means the date the health care entity or health plan receives the

credentialing application whether via electronic submission or as a paper application.

     (2) "Health care entity" means a licensed insurance company or nonprofit hospital or

medical or dental service corporation or plan or health maintenance organization, or a contractor

as defined in §23-17.13-2 which operates a health plan.

     (3) "Health care provider" means a health care professional or a health care facility.

     (4) "Health plan" means a plan operated by a health care entity that provides for the

delivery of health care services to persons enrolled in those plans through:

LC004849 - Page 2 of 9

     (i) Arrangements with selected providers to furnish health care services; and

     (ii) Financial incentives for persons enrolled in the plan to use the participating providers

and procedures provided for by the health plan.

     SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service

Corporations" is hereby amended by adding thereto the following section:

     27-19-73. Health care provider credentialing. – (a) A health care entity or health plan

operating in the state shall be required to issue a decision regarding the credentialing of a health

care provider within twenty (20) calendar days of the date of receipt of a complete credentialing

application. In all cases, the health care entity or health plan must take action on the application

within ninety (90) days of receipt of the application. whether or not the application is complete.

     (1) Each health care entity or health plan shall establish a written standard defining what

elements constitute a complete credentialing application and shall distribute this standard with the

written version of the credentialing application and make such standard available on the health

care entity's or health plan's website.

     (2) The health care entity or health plan shall not consider the following when

determining if a credentialing application is complete:

     (i) Whether the health care provider has been granted medical staff privileges at a health

care facility;

     (ii) Whether the health care entity or health plan has completed an evaluation that is

entirely at the discretion of the health care entity or health plan, such as a site visit or chart

review; or

     (iii) Whether the health care entity or health plan has received letters of reference on

behalf of the health care provider.

     (b) Each health care entity or health plan shall establish a database on its website to

update health care providers regarding the status of each health care provider's credentialing

application and listing any items required before the health care entity or health plan will deem

the credentialing application complete. The database shall be updated within seven (7) calendar

days of the date of receipt of any items related to a health care provider's credentialing application

and within seven (7) calendar days of any change to a health care provider's credentialing status.

     (c)(l) If the health care entity or health plan denies a credentialing application, the health

care entity or health plan shall notify the health care provider in writing within twenty (20)

calendar days from the date of receipt of the credentialing application and shall provide the health

care provider with any and all reasons for denying the credentialing application and what, if any,

additional information is required to complete the credentialing application.

LC004849 - Page 3 of 9

     (2) If a credentialing application is denied due to a health care provider's failure to

provide one or more items needed for a complete credentialing application, the health care

provider shall have an opportunity to appeal such denial upon written request to the health care

entity or health plan within twenty (20) days of denial, which request shall include any missing

credentialing application items or documentation establishing that such items were previously

delivered to the health care entity or health plan. The health care entity or health plan shall render

a decision on the appeal within ten (10) days of the date of receipt of the health care provider's

written request.

     (d) The effective date for billing privileges for health care providers under a particular

health care entity or health plan shall be the later of the date of the receipt by the health care

entity or health plan of a complete credentialing application that was subsequently approved by

the health care entity or health plan, or the date the health care provider is licensed by the Rhode

Island department of health.

     (e) For the purposes of this section, the following definitions apply:

     (1) "Date of receipt" means the date the health care entity or health plan receives the

credentialing application whether via electronic submission or as a paper application.

     (2) "Health care entity" means a licensed insurance company or nonprofit hospital or

medical or dental service corporation or plan or health maintenance organization, or a contractor

as defined in §23-17 .13-2, which operates a health plan.

     (3) "Health care provider" means a health care professional or a health care facility.

     (4) "Health plan" means a plan operated by a health care entity that provides for the

delivery of health care services to persons enrolled in those plans through:

     (i) Arrangements with selected providers to furnish health care services; and

     (ii) Financial incentive for persons enrolled in the plan to use the participating providers

and procedures provided for by the health plan.

     SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service

Corporations" is hereby amended by adding thereto the following section:

     27-20-69. Health care provider credentialing. – (a) A health care entity or health plan

operating in the state shall be required to issue a decision regarding the credentialing of a health

care provider within twenty (20) calendar days of the date of receipt of a complete credentialing

application. In all cases, the health care entity or health plan must take action on the application

within ninety (90) days of receipt of the application, whether or not the application is complete.

     (1) Each health care entity or health plan shall establish a written standard defining what

elements constitute a complete credentialing application and shall distribute this standard with the

LC004849 - Page 4 of 9

written version of the credentialing application and make such standard available on the health

care entity's or health plan's website.

     (2) The health care entity or health plan shall not consider the following when

determining if a credentialing application is complete:

     (i) Whether the health care provider has been granted medical staff privileges at a health

care facility;

     (ii) Whether the health care entity or health plan has completed an evaluation that is

entirely at the discretion of the health care entity or health plan, such as a site visit or chart

review; or

     (iii) Whether the health care entity or health plan has received letters of reference on

behalf of the health care provider.

     (b) Each health care entity or health plan shall establish a database on its website to

update health care providers regarding the status of each health care provider's credentialing

application and listing any items required before the health care entity or health plan will deem

the credentialing application complete. The database shall be updated within seven (7) calendar

days of the date of receipt of any items related to a health care provider's credentialing application

and within seven (7) calendar days of any change to a health care provider's credentialing status.

     (c)(l) If the health care entity or health plan denies a credentialing application. the health

care entity or health plan shall notify the health care provider in writing within twenty (20)

calendar days from the date of receipt of the credentialing application and shall provide the health

care provider with any and all reasons for denying the credentialing application and what. if any.

additional information is required to complete the credentialing application.

     (2) If a credentialing application is denied due to a health care provider's failure to

provide one or more items needed for a complete credentialing application, the health care

provider shall have an opportunity to appeal such denial upon written request to the health care

entity or health plan within twenty (20) days of denial, which request shall include any missing

credentialing application items or documentation establishing that such items were previously

delivered to the health care entity or health plan. The health care entity or health plan shall render

a decision on the appeal within ten (10) days of the date of receipt of the health care provider's

written request.

     (d) The effective date for billing privileges for health care providers under a particular

health care entity or health plan shall be the later of the date of the receipt by the health care

entity or health plan of a complete credentialing application that was subsequently approved by

the health care entity or health plan, or the date the health care provider is licensed by the Rhode

LC004849 - Page 5 of 9

Island department of health.

     (e) For the purposes of this section, the following definitions apply:

     (1) "Date of receipt" means the date the health care entity or health plan receives the

credentialing application whether via electronic submission or as a paper application.

     (2) "Health care entity" means a licensed insurance company or nonprofit hospital or

medical or dental service corporation or plan or health maintenance organization, or a contractor

as defined in §23-17.13-2, which operates a health plan.

     (3) "Health care provider" means a health care professional or a health care facility.

     (4) "Health plan" means a plan operated by a health care entity that provides for the

delivery of health care services to persons enrolled in those plans through:

     (i) Arrangements with selected providers to furnish health care services; and

     (ii) Financial incentives for persons enrolled in the plan to use the participating providers

and procedures provided for by the health plan.

     SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance

Organizations" is hereby amended by adding thereto the following section:

     27-41-86. Health care provider credentialing. – (a) A health care entity or health plan

operating in the state shall be required to issue a decision regarding the credentialing of a health

care provider within twenty (20) calendar days of the date of receipt of a complete credentialing

application. In all cases. the health care entity or health plan must take action on the application

within ninety (90) days of receipt of the application, whether or not the application is complete.

     (1) Each health care entity or health plan shall establish a written standard defining what

elements constitute a complete credentialing application and shall distribute this standard with the

written version of the credentialing application and make such standard available on the health

care entity's or health plan's website.

     (2) The health care entity or health plan shall not consider the following when

determining if a credentialing application is complete:

     (i) Whether the health care provider has been granted medical staff privileges at a health

care facility;

     (ii) Whether the health care entity or health plan has completed an evaluation that is

entirely at the discretion of the health care entity or health plan. such as a site visit or chart

review; or

     (iii) Whether the health care entity or health plan has received letters of reference on

behalf of the health care provider.

     (b) Each health care entity or health plan shall establish a database on its website to

LC004849 - Page 6 of 9

update health care providers regarding the status of each health care provider's credentialing

application and listing any items required before the health care entity or health plan will deem

the credentialing application complete. The database shall be updated within seven (7) calendar

days of the date of receipt of any items related to a health care provider's credentialing application

and within seven (7) calendar days of any change to a health care provider's credentialing status.

     (c)(l) If the health care entity or health plan denies a credentialing application, the health

care entity or health plan shall notify the health care provider in writing within twenty (20)

calendar days from the date of receipt of the credentialing application and shall provide the health

care provider with any and all reasons for denying the credentialing application and what. if any.

additional information is required to complete the credentialing application.

     (2) If a credentialing application is denied due to a health care provider's failure to

provide one or more items needed for a complete credentialing application, the health care

provider shall have an opportunity to appeal such denial upon written request to the health care

entity or health plan within twenty (20) days of denial, which request shall include any missing

credentialing application items or documentation establishing that such items were previously

delivered to the health care entity or health plan. The health care entity or health plan shall render

a decision on the appeal within ten (10) days of the date of receipt of the health care provider's

written request.

     (d) The effective date for billing privileges for health care providers under a particular

health care entity or health plan shall be the later of the date of the receipt by the health care

entity or health plan of a complete credentialing application that was subsequently approved by

the health care entity or health plan, or the date the health care provider is licensed by the Rhode

Island department of health.

     (e) For the purposes of this section. the following definitions apply:

     (1) "Date of receipt" means the date the health care entity or health plan receives the

credentialing application whether via electronic submission or as a paper application.

     (2) "Health care entity" means a licensed insurance company or nonprofit hospital or

medical or dental service corporation or plan or health maintenance organization, or a contractor

as defined in §23-17.13-2, which operates a health plan.

     (3) "Health care provider" means a health care professional or a health care facility.

     (4) "Health plan" means a plan operated by a health care entity that provides for the

delivery of health care services to persons enrolled in those plans through:

     (i) Arrangements with selected providers to furnish health care services; and

     (ii) Financial incentives for persons enrolled in the plan to use the participating providers

LC004849 - Page 7 of 9

and procedures provided for by the health plan.

     SECTION 5. This act shall take effect upon passage.

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LC004849

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

***

     This act would require a health care entity or health plan to issue a decision regarding the

credentialing of a health care provider within twenty (20) days of receiving a complete

credentialing application and would establish the effective date for billing privileges for health

care providers as the later of the date of the receipt of the complete credentialing application, or

the date the health care provider is licensed by the Rhode Island department of health.

     This act would take effect upon passage.

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LC004849

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LC004849 - Page 9 of 9