Citations Affected: IC 27-8; IC 27-13.
Synopsis: Health care provider credentialing. Specifies a credentialing
application form for use in accident and sickness insurer and health
maintenance organization provider credentialing activities. Requires
certain provider notifications. Exempts certain providers.
Effective: July 1, 2005.
January 4, 2005, read first time and referred to Committee on Health and Provider
February 3, 2005, reported favorably _ Do Pass.
February 7, 2005, read second time, amended, ordered engrossed.
February 8, 2005, engrossed. Read third time, passed. Yeas 50, nays 0.
A BILL FOR AN ACT to amend the Indiana Code concerning
SECTION 1. IC 27-8-11-1 IS AMENDED TO READ AS
FOLLOWS [EFFECTIVE JULY 1, 2005]: Sec. 1.
As used in (a) The
definitions in this section apply throughout this chapter.
(b) "Credentialing" means a process through which an insurer makes a determination:
(1) based on criteria established by the insurer; and
(2) concerning whether a provider is eligible to:
(A) provide health care services to an insured; and
(B) receive reimbursement for the health care services;
under an agreement entered into between the provider and the insurer under section 3 of this chapter.
(c) "Health care services":
(1) means health care related services or products rendered or sold by a provider within the scope of the provider's license or legal authorization; and
(2) includes hospital, medical, surgical, dental, vision, and pharmaceutical services or products.
(1) based on criteria established by the health maintenance organization; and
(2) concerning whether a provider may serve as a participating provider.
SECTION 4. IC 27-13-43 IS ADDED TO THE INDIANA CODE AS A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE JULY 1, 2005]:
Chapter 43. Credentialing
Sec. 1. (a) Except as provided in subsection (b), this chapter applies to a health maintenance organization that provides basic health care services.
(b) This chapter does not apply to the credentialing of a provider by a health maintenance organization if the provider's application for credentialing is only for purposes of providing health care services to the following:
(1) A Medicaid recipient under a Medicaid risk based managed care program described in IC 12-15-12.
(2) An individual who is covered under the children's health insurance program established under IC 12-17.6-2.
Sec. 2. (a) The department shall prescribe the credentialing application form used by the Council for Affordable Quality Healthcare (CAQH) in electronic or paper format, which must be used by:
(1) a provider who applies for credentialing by a health maintenance organization; and
(2) a health maintenance organization that performs credentialing activities.
(b) A health maintenance organization shall notify a provider concerning a deficiency on a completed credentialing application form submitted by the provider not later than thirty (30) business days after the health maintenance organization receives the completed credentialing application form.
(c) A health maintenance organization shall notify a provider concerning the status of the provider's completed credentialing application not later than:
(1) sixty (60) days after the health maintenance organization receives the completed credentialing application form; and
(2) every thirty (30) days after the notice is provided under subdivision (1), until the health maintenance organization makes a final credentialing determination concerning the provider.