Credentialing procedure, health carrier duties — covered health services, payment, when — violations, mechanism for reporting
See bold text below:
1. Within two working days after receipt of a credentialing application, the health carrier shall send a notice of receipt to the practitioner. A health carrier shall provide access to a provider web portal that allows the practitioner to receive notice of the status of an electronically submitted application.
2. If a health carrier determines the application is not a completed application, the health carrier shall have ten days from the date the notice of receipt was sent as required in subsection 1 of this section to request any additional information from the practitioner. The application shall be considered a completed application upon receipt of the requested additional information from the practitioner. Within two working days of receipt of the requested additional information, the health carrier shall send a notice to the practitioner informing him or her that he or she has submitted a completed application. If the health carrier does not request additional information, the application shall be deemed completed as of the date the notice of receipt was sent as required under subsection 1 of this section.
3. A health carrier shall assess a health care practitioner’s completed credentialing application and make a decision as to whether to approve or deny the practitioner’s credentialing application and notify the practitioner of such decision within sixty days of the date of receipt of the completed application. The sixty-day deadline established in this section shall not apply if the application or subsequent verification of information indicates that the practitioner has:
(1) A history of behavioral disorders or other impairments affecting the practitioner’s ability to practice, including but not limited to substance abuse;
(2) Licensure disciplinary actions against the practitioner’s license to practice imposed by any state or territory or foreign jurisdiction;
(3) Had the practitioner’s hospital admitting or surgical privileges or other organizational credentials or authority to practice revoked, restricted, or suspended based on the practitioner’s clinical performance; or
(4) A judgment or judicial award against the practitioner arising from a medical malpractice liability lawsuit.
Credentialing-Payment Issues/Claims Filing Deadlines
4. If a practitioner’s application is approved, the health carrier shall provide payments for covered health services performed by the practitioner during the credentialing period if the provision of services was on behalf of an entity that had a contract with such health carrier during the credentialing period. The contracted entity for which the practitioner is providing services shall submit to the health carrier all claims for services provided by such practitioner during the credentialing period within six months after the health carrier has approved that practitioner’s credentialing application. Claims submitted for reimbursement under this section shall be sent to the carrier by the provider in a single request or as few requests as practical subject to any technical constraints or other issues out of the contracted provider’s control. “Credentialing period” shall mean the time between the date the practitioner submits a completed application to the health carrier to be credentialed and the date the practitioner’s credentialing is approved by the health carrier. No practitioner that has submitted an application in accordance with the provisions of this subsection shall send any claim to the patient for charges incurred for care of the patient during the credentialing period with the patient’s health carrier.
5. A health carrier shall not require a practitioner to be credentialed in order to receive payments for covered patient care services if the practitioner is providing coverage for an absent credentialed practitioner during a temporary period of time not to exceed:
(1) Sixty days if the reason for the absence of the credentialed practitioner is for any of the conditions described in 29 CFR 825.113, 29 CFR 825.115, or 29 CFR 825.120, or any amendments or successor regulations thereto; or
(2) Thirty days if the reason for the absence of the credentialed practitioner is not otherwise provided for under subdivision (1) of this subsection.
Any practitioner authorized to receive payments for covered services under this section shall provide notice to the health carrier, including, but not limited to, the absent practitioner’s name, medical license information, and estimated duration of absence and the name and medical license information of the practitioner providing coverage for such absent credentialed practitioner. A health carrier may deny payments if the practitioner providing services in lieu of the credentialed provider meets one of the conditions in subdivisions (1) to (4) of subsection 3 of this section.
6. All claims eligible for payment under subsection 4 or 5 of this section shall be subject to section 376.383.
7. For the purposes of this section, “covered health services” shall mean any services provided by a practitioner that would otherwise be covered if provided by a credentialed provider.
8. The department of commerce and insurance shall establish a mechanism for reporting alleged violations of this section to the department.