Health care provider credentialing
See bold sections below:
(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 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.