Citations Affected: IC 27-8-11; 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
Services.
A BILL FOR AN ACT to amend the Indiana Code concerning
insurance.
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.
a determination:
(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 fourteen (14)
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.