The act requires that when a physician applies to be credentialed as a participating physician in a health insurance carrier's (carrier's) provider network, the carrier must conclude the process of credentialing the applicant within 60 calendar days after the carrier receives the applicant's completed application. A carrier must provide each applicant written or electronic notice of the outcome of the applicant's credentialing within 10 calendar days after the conclusion of the credentialing process.
Within 7 calendar days after a carrier receives an application, the carrier must provide the applicant a receipt. If a carrier receives an application but fails to provide the applicant a receipt within 7 calendar days, the carrier shall consider the applicant a participating physician, effective no later than 53 calendar days following the carrier's receipt of the application.
A carrier may not deny a claim for a medically necessary covered service provided to a covered person if the service:
- Is a covered benefit under the covered person's health coverage plan; and
- Is provided by a participating physician who is in the provider network for the carrier's health coverage plan and has concluded the carrier's credentialing process.
A carrier may not require a participating physician to submit an application or participate in a contracting process in order to be recredentialed.
With certain exceptions, a carrier must allow a participating physician to remain credentialed and include the participating physician in the carrier's provider network unless the carrier discovers information indicating that the participating physician no longer satisfies the carrier's guidelines for participation.
The commissioner of insurance is required to enforce the new requirements. A carrier that fails to comply with the act or with any rules adopted pursuant to the act is subject to such civil penalties as the commissioner may order.
To implement the act, for the 2021-22 state fiscal year, the act appropriates $52,505 to the department of regulatory agencies from the division of insurance cash fund. Of this amount, $21,268 is reappropriated to the department of law for legal services.
(Note: This summary applies to this bill as enacted.)