Uniform provider credentialing
See bold text below:
(a) Definitions. — As used in this section:
(1) “Credentialing” means a process through which an insurer or hospital makes a determination, based on criteria established by the insurer or hospital, concerning whether a provider is eligible to:
(A) provide health care services to an insured or hospital patients; and
(B) receive reimbursement for the health care services.
(2) “Health care services” means health-care-related services or products rendered or sold by a provider within the scope of the provider’s license or legal authorization, including hospital, medical, surgical, dental, vision, and pharmaceutical services or products.
(3) “Insured” means an individual entitled to reimbursement for expenses of health care services under a policy issued or administered by an insurer.
(4) “Insurer” has the same meaning as in subdivision 9402(8) of this title.
(5) “Provider” has the same meaning as in subdivision 9402(7) of this title.
(b) The Department shall prescribe the credentialing application form used by the Council for Affordable Quality Healthcare (CAQH), or a similar, nationally recognized form prescribed by the Commissioner, in electronic or paper format, which must be used beginning January 1, 2007 by an insurer or a hospital that performs credentialing. The Commissioner may grant a hospital an extension to the implementation date for up to one year.
(c) An insurer or a hospital shall notify a provider concerning a deficiency on a completed credentialing application form submitted by the provider not later than 30 business days after the insurer or hospital receives the completed credentialing application form.
(d) A hospital shall notify a provider concerning the status of the provider’s completed credentialing application not later than:
(1) 60 days after the hospital receives the completed credentialing application form; and
(2) every 30 days after the notice is provided under subdivision (1) of this subsection, until the hospital makes a final credentialing determination concerning the provider.
(f) An insurer shall act upon and finish the credentialing process of a completed application submitted by a provider within 60 calendar days after receipt of the application. An application shall be considered complete once the insurer has received all information and documentation necessary to make its credentialing determination as provided in subsections (b) and (c) of this section.