2017 -- H 5219 SUBSTITUTE A

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LC000820/SUB A

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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.

4

     (a) For applications received on or after January 1, 2018, a health care entity or health

5

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

6

health care provider as soon as practicable, but no later than forty-five (45) calendar days after the

7

date of receipt of a complete credentialing application.

8

     (b) For minor changes to the demographic information of an individual health care

9

provider who is already credentialed with a particular health care entity or health plan, such

10

health care entity or health plan shall complete such change within seven (7) business days of

11

receipt of the health care provider's request. Minor changes to demographic information requested

12

by individual providers shall be submitted in the timeframe, and manner required by the health

13

care entity or health plan, and shall include all supporting documentation required by the

14

particular health care entity or health plan. For purposes of this section, minor changes to the

15

information profile of a health care provider shall include, but not be limited to, changes of

16

address and changes to a health care provider's tax identification number.

17

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

18

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

19

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

 

1

care entity's or health plan's website.

2

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

3

regarding the status of an application.

4

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

5

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

6

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

7

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

8

business days that the credentialing application is complete; and

9

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

10

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

11

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

12

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

13

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

14

the credentialing application.

15

     (f) For applications received from resident graduates on or after January 1, 2018, a health

16

care entity or health plan shall offer a transitional or conditional approval process such that a

17

resident graduate who has submitted an otherwise complete application and met all other criteria,

18

may be conditionally approved, effective upon successful graduation from the training program.

19

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

20

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

21

submitted.

22

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

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

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

32

and procedures provided for by the health plan.

33

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

34

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

 

LC000820/SUB A - Page 2 of 8

1

     27-19-74. Health care provider credentialing.

2

     (a) For applications received on or after January 1, 2018, a health care entity or health

3

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

4

health care provider as soon as practicable, but no later than forty-five (45) calendar days after the

5

date of receipt of a complete credentialing application.

6

     (b) For minor changes to the demographic information of an individual health care

7

provider who is already credentialed with a particular health care entity or health plan, such

8

health care entity or health plan shall complete such change within seven (7) business days of

9

receipt of the health care provider's request. Minor changes to demographic information requested

10

by individual providers shall be submitted in the timeframe, and manner required by the health

11

care entity or health plan, and shall include all supporting documentation required by the

12

particular health care entity or health plan. For purposes of this section, minor changes to the

13

information profile of a health care provider shall include, but not be limited to, changes of

14

address and changes to a health care provider's tax identification number.

15

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

16

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

17

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

18

care entity's or health plan's website.

19

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

20

regarding the status of an application.

21

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

22

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

23

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

24

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

25

business days that the credentialing application is complete; and

26

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

27

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

28

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

29

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

30

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

31

the credentialing application.

32

     (f) For applications received from resident graduates on or after January 1, 2018, a health

33

care entity or health plan shall offer a transitional or conditional approval process such that a

34

resident graduate who has submitted an otherwise complete application and met all other criteria,

 

LC000820/SUB A - Page 3 of 8

1

may be conditionally approved, effective upon successful graduation from the training program.

2

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

3

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

4

submitted.

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

and procedures provided for by the health plan.

16

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

17

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

18

     27-20-70. Health care provider credentialing.

19

     (a) For applications received on or after January 1, 2018, a health care entity or health

20

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

21

health care provider as soon as practicable, but no later than forty-five (45) calendar days after the

22

date of receipt of a complete credentialing application.

23

     (b) For minor changes to the demographic information of an individual health care

24

provider who is already credentialed with a particular health care entity or health plan, such

25

health care entity or health plan shall complete such change within seven (7) business days of

26

receipt of the health care provider's request. Minor changes to demographic information requested

27

by individual providers shall be submitted in the timeframe, and manner required by the health

28

care entity or health plan, and shall include all supporting documentation required by the

29

particular health care entity or health plan. For purposes of this section, minor changes to the

30

information profile of a health care provider shall include, but not be limited to, changes of

31

address and changes to a health care provider's tax identification number.

32

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

33

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

34

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

 

LC000820/SUB A - Page 4 of 8

1

care entity's or health plan's website.

2

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

3

regarding the status of an application;

4

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

5

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

6

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

7

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

8

business days that the credentialing application is complete; and

9

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

10

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

11

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

12

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

13

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

14

the credentialing application.

15

     (f) For applications received from resident graduates on or after January 1, 2018, a health

16

care entity or health plan shall offer a transitional or conditional approval process such that a

17

resident graduate who has submitted an otherwise complete application and met all other criteria,

18

may be conditionally approved, effective upon successful graduation from the training program.

19

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

20

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

21

submitted.

22

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

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

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

32

and procedures provided for by the health plan.

33

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

34

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

 

LC000820/SUB A - Page 5 of 8

1

     27-41-87. Health care provider credentialing.

2

     (a) For applications received on or after January 1, 2018, a health care entity or health

3

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

4

health care provider as soon as practicable, but no later than forty-five (45) calendar days after the

5

date of receipt of a complete credentialing application.

6

     (b) For minor changes to the demographic information of an individual health care

7

provider who is already credentialed with a particular health care entity or health plan, such

8

health care entity or health plan shall complete such change within seven (7) business days of

9

receipt of the health care provider's request. Minor changes to demographic information requested

10

by individual providers shall be submitted in the timeframe, and manner required by the health

11

care entity or health plan, and shall include all supporting documentation required by the

12

particular health care entity or health plan. For purposes of this section, minor changes to the

13

information profile of a health care provider shall include, but not be limited to, changes of

14

address and changes to a health care provider's tax identification number.

15

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

16

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

17

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

18

care entity's or health plan's website.

19

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

20

regarding the status of an application.

21

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

22

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

23

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

24

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

25

business days that the credentialing application is complete; and

26

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

27

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

28

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

29

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

30

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

31

the credentialing application.

32

     (f) For applications received from resident graduates on or after January 1, 2018, a health

33

care entity or health plan shall offer a transitional or conditional approval process such that a

34

resident graduate who has submitted an otherwise complete application and met all other criteria,

 

LC000820/SUB A - Page 6 of 8

1

may be conditionally approved, effective upon successful graduation from the training program.

2

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

3

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

4

submitted.

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

and procedures provided for by the health plan.

16

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

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LC000820/SUB A - Page 7 of 8

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/SUB A - Page 8 of 8