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

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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:

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

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

     27-18-83. Health care provider credentialing.

     (a) For applications received on or after January 1, 2018, 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 as soon as practicable, but no later than forty-five (45) calendar days after the

date of receipt of a complete credentialing application.

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

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

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

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

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

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

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

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

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

     (c) 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.

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

regarding the status of an application.

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

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

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

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

business days that the credentialing application is complete; and

     (3) 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 and shall provide the

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

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

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

the credentialing application.

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

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

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

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

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

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

submitted.

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

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

     (3) "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.

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

     (5) "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 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service

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

LC000820/SUB A - Page 2 of 8

     27-19-74. Health care provider credentialing.

     (a) For applications received on or after January 1, 2018, 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 as soon as practicable, but no later than forty-five (45) calendar days after the

date of receipt of a complete credentialing application.

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

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

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

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

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

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

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

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

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

     (c) 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.

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

regarding the status of an application.

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

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

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

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

business days that the credentialing application is complete; and

     (3) 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 and shall provide the

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

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

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

the credentialing application.

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

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

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

LC000820/SUB A - Page 3 of 8

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

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

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

submitted.

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

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

     (3) "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.

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

     (5) "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 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service

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

     27-20-70. Health care provider credentialing.

     (a) For applications received on or after January 1, 2018, 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 as soon as practicable, but no later than forty-five (45) calendar days after the

date of receipt of a complete credentialing application.

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

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

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

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

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

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

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

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

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

     (c) 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

LC000820/SUB A - Page 4 of 8

care entity's or health plan's website.

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

regarding the status of an application;

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

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

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

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

business days that the credentialing application is complete; and

     (3) 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 and shall provide the

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

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

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

the credentialing application.

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

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

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

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

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

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

submitted.

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

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

     (3) "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.

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

     (5) "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:

LC000820/SUB A - Page 5 of 8

     27-41-87. Health care provider credentialing.

     (a) For applications received on or after January 1, 2018, 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 as soon as practicable, but no later than forty-five (45) calendar days after the

date of receipt of a complete credentialing application.

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

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

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

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

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

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

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

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

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

     (c) 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.

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

regarding the status of an application.

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

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

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

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

business days that the credentialing application is complete; and

     (3) 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 and shall provide the

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

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

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

the credentialing application.

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

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

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

LC000820/SUB A - Page 6 of 8

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

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

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

submitted.

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

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

     (3) "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.

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

     (5) "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 5. This act shall take effect on January 1, 2018.

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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 forty-five (45) calendar days of receiving a

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

establish a written standard defining what elements constitute a complete credentialing

application and provide applicants with regular status updates throughout the credentialing

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

compliance standards and enforcement provisions consistent with this section.

     This act would take effect on January 1, 2018.

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