HB2322 - 532R - Senate Fact Sheet

ARIZONA STATE SENATE

Fifty-Third Legislature, Second Regular Session

AMENDED

FACT SHEET FOR H.B. 2322

health insurers; provider credentialing

Purpose

Requires health insurers to establish an electronic process for the submission of credentialing applications and supporting documentation by January 1, 2019. Establishes that the process of credentialing and loading an application must conclude within 100 days after a health insurer receives a completed application.

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 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%

There is no anticipated fiscal impact to the state General Fund associated with this legislation.

Provisions

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 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.

21. Becomes effective on January 1, 2019.