Assigned to HHS AS
PASSED BY COW
Assigned to HHS AS
PASSED BY COW
ARIZONA STATE SENATE
Fifty-Third Legislature, Second Regular Session
AMENDED
health insurers; provider credentialing
Purpose
Effective January 1, 2019, requires health insurers to establish an electronic process for the submission of credentialing applications and supporting documentation. Establishes that the process of credentialing and loading an application must conclude within 100 days after a health insurer receives a completed application. Modifies certain representational requirements for directors of hospital service corporations, medical service corporations, hospital and medical service corporations and optometric service corporations.
Background
According to the Department of Health Services (DHS), credentialing is the process of obtaining, verifying and assessing information to determine whether a health professional or a health technician has the required credentials to provide specified health services to persons enrolled in a health insurance plan. It also includes the review and primary source verification of applicable licensure, accreditation and certification of health care providers, including determining the validity of a license, certification, training and work experience (DHS Division of Behavioral Health Services Provider Manual). Currently, there is no established timeline in statute for a health insurer to complete provider credentialing. The Arizona Health Care Cost Containment System (AHCCCS) established a policy to cover temporary and provisional credentialing, credentialing, and recredentialing requirements for both individual and organizational providers (AHCCCS Medical Policy Manual, Chapter 900, Policy 950). The policy addresses all providers and establishes the following credentialing timelines:
|
Credentialing Activity |
Time Frame |
Completion Requirements |
|
Provisional |
14 days |
100% |
|
Initial |
90 days |
100% |
|
Organizational Credentialing |
90 days |
100% |
|
Recredentialing |
Every three years |
100% |
|
Load Time (time between Credentialing Committee approval and loading into claims system) |
30 days |
90% |
Current law defines hospital service corporations, medical service corporations, dental service corporations and hospital, medical, dental and optometric service corporations as corporations organized under Arizona law for the purpose of establishing, maintaining and operating nonprofit hospital, medical, dental or optometric service plans, or a combination of such plans (A.R.S. § 20-822). Statute requires directors of such corporations to include the following representation: 1) for a hospital service corporation or a hospital and medical service corporation, administrators or trustees of hospitals contracted with the corporation; 2) for a medical service corporation or a hospital and medical service corporation, licensed physicians and surgeons contracted with the corporation; 3) for a dental service corporation, licensed dentists contracted with the corporation; 4) for an optometric service corporation, licensed optometrists contracted with the corporation; and 5) members of the general public, excluding hospital representatives and physicians, dentists and optometrists (A.R.S. § 20-829).
There is no anticipated fiscal impact to the state General Fund associated with this legislation.
Provisions
Provider Credentialing
1. Requires, by January 1, 2020, health insurers to establish an electronic process for the submission of a credentialing applications and supporting documentation and to adopt a standard application.
2. Establishes that the process of credentialing and loading an application must conclude within 100 days after a health insurer receives a completed application.
3. Exempts a health insurer from the prescribed 100-day timeline if the applicant works at the licensed health care facility and the facility has a delegated credentialing agreement with a health insurer that requires the loading process for that applicant to be concluded in ten calendar days after receiving a roster of demographic changes.
4. Directs a health insurer to provide written or electronic notice of the approval or denial of a credentialing application within seven days after the conclusion of the credentialing process.
5. Directs a health insurer to provide written or electronic acknowledgement of receipt to an applicant within seven days after receipt of an application and requires that an applicant include specified contact information in the application.
6. Requires health insurers to promptly review applications to determine if they are complete, and directs a health insurer who determines an application is incomplete to notify the applicant and provide a list of items required to complete the application within seven days after the application is received.
7. Authorizes a health insurer to request supplemental information to complete the credentialing process.
8. Requires a health insurer, upon receipt of a complete application, to send an applicant a proposed contract that is ready for execution.
9. Stipulates that an application is deemed complete if a health insurer fails to provide notice to the applicant as prescribed.
10. Tolls prescribed timeframes for credentialing application completion if a health insurer notifies an applicant of an incomplete application.
11. Authorizes an insurer to deem that an application is withdrawn if no response is received from the applicant within 30 days of issuing a notice of an incomplete application.
12. States that a health insurer that enters into a delegated credentialing agreement with a licensed health care facility or that participates in a health insurer credentialing alliance with equivalent or higher standards than those prescribed is deemed to be in compliance with applicant notification requirements.
13. Requires a health insurer to take reasonable steps to correct discrepancies in the provider or network plan directory within 30 days of receiving notification of a discrepancy from a participating provider, and directs participating providers to update specified contact information within 10 business days.
14. Prohibits a health insurer from denying a claim for a covered service provided to a subscriber by a participating provider who has a fully executed contract with a network plan if the services are provided after the date a credentialing application is approved.
15. Directs a health insurer to make the following nonproprietary information available on its website:
a) the applicable credentialing policies and procedures;
b) a list of all the information required for a credentialing application;
c) a checklist of materials that must be submitted in the credentialing process; and
d) designated contact information.
16. Requires health insurers to make all nonproprietary information pertaining to a provider's credentialing application and final decisions available to an applicant on request.
17. Allows a health insurer to recredential a participating provider once every 36 months, or more frequently if required by federal or state law or health insurer's accreditation standards.
18. Requires a participating provider to remain credentialed and loaded in the health insurer's billing system unless the insurer discovers information that violates the insurer's guidelines.
19. Grants immunity from civil liability to any health insurer that complies in good faith with credentialing requirements.
20. Authorizes the Director of Insurance (Director) to enforce established credentialing requirements and subjects a health insurer who fails to comply with requirements to prescribed civil penalties.
Health Insurance Corporation Director Requirements
21. Eliminates the requirement that directors of a hospital service corporation or a hospital and medical service corporation include representatives who are administrators or trustees of contracted hospitals.
22. Eliminates the requirement that directors of a medical service corporation or a hospital and medical service corporation include representatives who are contracted licensed physicians and surgeons.
23. Removes the requirement that a majority of directors of a dental service corporation be contracted dentists.
Miscellaneous
24. Makes technical and conforming changes.
25. Becomes effective on January 1, 2019
Amendments Adopted by Committee
1. Adds that credentialing may occur more frequently if required by federal or state law or health insurer's accreditation standards.
2. Allows an insurer to remove a participating provider from their system if the insurer discovers information that violates the insurer's guidelines.
Amendments Adopted by Committee of the Whole
1. Modifies certain representational requirements for health insurance corporation directors.
2. Makes technical and conforming changes.
House Action Senate Action
Health 2/15/18 DPA 9-0-0-0 HHS 3/15/18 DPA 6-0-1
3rd Read 2/22/18 DPA 56-4-0 3rd Read 4/5/18 28-0-2
Prepared by Senate Research
April 5, 2018
CRS/NW/lat