Chapter 185
2017 -- H 5219 SUBSTITUTE A
Enacted 07/18/2017

A N   A C T
RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

Introduced By: Representatives McKiernan, O'Brien, Regunberg, Ranglin-Vassell, and
Date Introduced: January 26, 2017

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 that 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:
     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,
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 that 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
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 that 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:
     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,
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 that 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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LC000820/SUB A
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