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ARIZONA HOUSE OF REPRESENTATIVESFifty-seventh Legislature First Regular Session |
Senate: HHS DPA/SE 6-0-1-0 | 3rd Read 29-0-1-0 |
SB 1291: health insurers; provider credentialing; claims
Sponsor: Senator Angius, LD 30
Committee on Health & Human Services
Overview
Makes modifications to deadlines of the health insurance provider credentialing process and outlines requirements for processing of claims effective April 1, 2026.
History
A health insurer includes a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation, medical service corporation or a hospital, medical, dental and optometric service corporation and health insurer's designee (A.R.S. § 20-3451).
Health care provider credentialing is a process used by health insurers to collect, verify and assess whether a provider meets relevant licensing, education and training requirements to become or remain a participating provider. Health insurers must conclude the process of credentialing and loading an applicant's information into the insurer's billing system within 100 days of receipt of an application. Health insurers are prohibited 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 of approval of the credentialing application (A.R.S. Title 20, Chapter 27).
Provisions
1. Requires a health insurer to:
a) conclude the provider credentialing process within 60 calendar days; and
b) load the applicant's information into the insurer's billing system within 30 calendar days, rather than 100 calendar days, upon receipt of a complete credentialing application. (Sec. 2)
2. Requires a health insurer, within seven calendar days of receiving a credentialing application, to:
a) contact the applicant in writing or electronically to acknowledge receipt of the application; and
b) inform the applicant whether the application is a complete credentialing application. (Sec. 3)
3. Requires credentialing applicants to include the email address of an individual who can address discrepancies in the application. (Sec. 3)
4. Specifies that a health insurer must include a detailed list of all incomplete items in its incomplete credentialing application notices. (Sec. 3)
5. Specifies that, if a credentialing application is incomplete and requires additional information from the applicant, the health insurer must:
a) contact the applicant within seven calendar days to acknowledge receipt of the submitted additional information; and
b) inform the applicant whether the application is complete. (Sec. 3)
6. Requires health insurers to communicate the withdrawal of an application to the applicant within 7 calendar days, if the insurer has not received any response from the applicant providing the requested information within 30 calendar days. (Sec. 3)
7. Specifies that, if the time period for processing a credentialing application is tolled while the health insurer waits for additional information, the health insurer must acknowledge, in writing or electronically, receipt of the additional information within seven calendar days. (Sec. 3)
8. Forbids health insurers from tolling the required application processing time period more than three times. (Sec. 3)
9. Permits a health insurer to deem an application withdrawn if, after the third toll, the insurer has not received a response from the applicant with additional information within 30 calendar days. (Sec. 3)
10. Permits a provider to receive payment from a health insurer for services provided from the date included on the notice of a complete credentialing application to the date the provider's network participation contract is executed. (Sec. 5)
11. Directs a health insurer to process a provider's claim as an in-network claim and pay the claim if the provider:
a) has applied for credentialing and renders a covered service to an individual who is an eligible health plan member on the date of service;
b) renders the service on or after the date that the health insurer notified the provider of a complete credentialing application; and
c) does not submit the claim until after the provider has a fully executed network participation contract with the health insurer for the member's health plan network and the health insurer has approved the provider's credentials. (Sec. 5)
12. Forbids, for claims submitted within one year after the date of service, health insurers from denying a provider's claim that is submitted in compliance with statute on the basis that the claim was not submitted within the contractually required time period. (Sec. 5)
13. Clarifies that health insurers are not required to reimburse an applicant at the in-network rate for any covered medical services provided by the applicant if the applicant's credentialing application is not approved or the health care provider is unwilling to contract with the insurer on mutually acceptable terms. (Sec. 5)
14. Requires, within a reasonable period before a health care provider provides services to a patient in a network facility, the provider or the provider's representative to provide a written, dated disclosure that includes:
a) the name of the billing health care provider;
b) the total estimated cost to be billed by the health care provider or the provider's representative; and
c) a statement that the provider is not credentialed and is not a contract provider. (Sec. 5)
15. Excludes a health insurer that does not credential a provider from civil liability for any act or omission of the provider in rendering services to a member. (Sec. 6)
16. Repeals statute that 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 of approval of the credentialing application. (Sec. 4)
17. Redefines credentialing as a complete credentialing application that includes:
a) all information, any required supporting documentation and a current authorization to access electronic documentation that a health insurer needs in order to process the credentialing request through a credentialing system that is developed by a nationally recognized alliance of health plans and trade associations; and
b) a nonprofit organization that is incorporated as a mutual health care corporation that is working to streamline the business of health care. (Sec. 1)
18. Revises the definition of participating provider to include a provider that has been contracted by a health insurer to provide health care items or services to subscribers. (Sec. 1)
19. Makes technical and conforming changes. (Sec. 1-3 and 6)
20. Contains an effective date of April 1, 2026. (Sec. 7)
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24. SB 1291
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