2017 -- H 5219

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LC000820

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2017

____________

A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

     

     Introduced By: Representatives McKiernan, O'Brien, Regunberg, Ranglin-Vassell, and
Williams

     Date Introduced: January 26, 2017

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

1

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

2

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

3

     27-18-83. Health care provider credentialing. – (a) For applications received on or

4

after January 1, 2018, a health care entity or health plan operating in the state shall be required to

5

issue a decision regarding the credentialing of a health care provider as soon as practicable, but

6

no later than forty-five (45) calendar days after the date of receipt of a complete credentialing

7

application.

8

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

9

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

10

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

11

care entity's or health plan's website.

12

     (c) Each health care entity or health plan shall respond to inquiries by the applicant

13

regarding the status of an application;

14

     (1) Each health care entity or health plan shall provide the applicant with automated

15

application status updates, at least once every fifteen (15) calendar days, informing the applicant

16

of any missing application materials until the application is deemed complete; and

17

     (2) Each health care entity or health plan shall inform the applicant within five (5)

18

business days that the credentialing application is complete.

19

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

 

1

care entity or health plan shall notify the health care provider in writing and shall provide the

2

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

3

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

4

health care entity or health plan shall be the next business day following the date of approval of

5

the credentialing application.

6

     (e) The office of the health insurance commissioner shall develop compliance standards

7

and enforcement provisions consistent with this section.

8

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

9

     (1) "Complete credentialing application" means all the requested material has been

10

submitted.

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19

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

20

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

21

and procedures provided for by the health plan.

22

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

23

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

24

     27-19-74. Health care provider credentialing. – (a) For applications received on or

25

after January 1, 2018, a health care entity or health plan operating in the state shall be required to

26

issue a decision regarding the credentialing of a health care provider as soon as practicable, but

27

no later than forty-five (45) calendar days after the date of receipt of a complete credentialing

28

application.

29

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

30

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

31

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

32

care entity's or health plan's website.

33

     (c) Each health care entity or health plan shall respond to inquiries by the applicant

34

regarding the status of an application;

 

LC000820 - Page 2 of 7

1

     (1) Each health care entity or health plan shall provide the applicant with automated

2

application status updates, at least once every fifteen (15) calendar days, informing the applicant

3

of any missing application materials until the application is deemed complete; and

4

     (2) Each health care entity or health plan shall inform the applicant within five (5)

5

business days that the credentialing application is complete.

6

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

7

care entity or health plan shall notify the health care provider in writing and shall provide the

8

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

9

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

10

health care entity or health plan shall be the next business day following the date of approval of

11

the credentialing application.

12

     (e) The office of the health insurance commissioner shall develop compliance standards

13

and enforcement provisions consistent with this section.

14

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

15

     (1) "Complete credentialing application" means all the requested material has been

16

submitted.

17

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

18

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

19

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

20

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

21

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

22

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

23

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

24

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

25

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

26

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

27

and procedures provided for by the health plan.

28

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

29

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

30

     27-20-70. Health care provider credentialing. – (a) For applications received on or

31

after January 1, 2018, a health care entity or health plan operating in the state shall be required to

32

issue a decision regarding the credentialing of a health care provider as soon as practicable, but

33

no later than forty-five (45) calendar days after the date of receipt of a complete credentialing

34

application.

 

LC000820 - Page 3 of 7

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

2

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

3

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

4

care entity's or health plan's website.

5

     (c) Each health care entity or health plan shall respond to inquiries by the applicant

6

regarding the status of an application;

7

     (1) Each health care entity or health plan shall provide the applicant with automated

8

application status updates, at least once every fifteen (15) calendar days, informing the applicant

9

of any missing application materials until the application is deemed complete; and

10

     (2) Each health care entity or health plan shall inform the applicant within five (5)

11

business days that the credentialing application is complete.

12

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

13

care entity or health plan shall notify the health care provider in writing and shall provide the

14

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

15

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

16

health care entity or health plan shall be the next business day following the date of approval of

17

the credentialing application.

18

     (e) The office of the health insurance commissioner shall develop compliance standards

19

and enforcement provisions consistent with this section.

20

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

21

     (1) "Complete credentialing application" means all the requested material has been

22

submitted.

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

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

32

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

33

and procedures provided for by the health plan.

34

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

 

LC000820 - Page 4 of 7

1

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

2

     27-41-87. Health care provider credentialing. – (a) For applications received on or

3

after January 1, 2018, a health care entity or health plan operating in the state shall be required to

4

issue a decision regarding the credentialing of a health care provider as soon as practicable, but

5

no later than forty-five (45) calendar days after the date of receipt of a complete credentialing

6

application.

7

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

8

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

9

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

10

care entity's or health plan's website.

11

     (c) Each health care entity or health plan shall respond to inquiries by the applicant

12

regarding the status of an application;

13

     (1) Each health care entity or health plan shall provide the applicant with automated

14

application status updates, at least once every fifteen (15) calendar days, informing the applicant

15

of any missing application materials until the application is deemed complete; and

16

     (2) Each health care entity or health plan shall inform the applicant within five (5)

17

business days that the credentialing application is complete.

18

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

19

care entity or health plan shall notify the health care provider in writing and shall provide the

20

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

21

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

22

health care entity or health plan shall be the next business day following the date of approval of

23

the credentialing application.

24

     (e) The office of the health insurance commissioner shall develop compliance standards

25

and enforcement provisions consistent with this section.

26

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

27

     (1) "Complete credentialing application" means all the requested material has been

28

submitted.

29

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

30

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

31

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

32

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

33

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

34

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

 

LC000820 - Page 5 of 7

1

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

2

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

3

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

4

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

5

and procedures provided for by the health plan.

6

     SECTION 5. This act shall take effect on January 1, 2018.

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LC000820

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LC000820 - Page 6 of 7

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

***

1

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

2

credentialing of a health care provider within forty-five (45) calendar days of receiving a

3

complete credentialing application. This act would require a health care entity or health plan to

4

establish a written standard defining what elements constitute a complete credentialing

5

application and provide applicants with regular status updates throughout the credentialing

6

process. It would also require that the office of the health insurance commissioner develop

7

compliance standards and enforcement provisions consistent with this section.

8

     This act would take effect on January 1, 2018.

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LC000820

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LC000820 - Page 7 of 7