Reprinted

February 8, 2005





SENATE BILL No. 43

_____


DIGEST OF SB 43 (Updated February 7, 2005 2:28 pm - DI 97)



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.





Gard, Breaux




    January 4, 2005, read first time and referred to Committee on Health and Provider Services.
    February 3, 2005, reported favorably _ Do Pass.
    February 7, 2005, read second time, amended, ordered engrossed.





Reprinted

February 8, 2005

First Regular Session 114th General Assembly (2005)


PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana Constitution) is being amended, the text of the existing provision will appear in this style type, additions will appear in this style type, and deletions will appear in this style type.
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SENATE BILL No. 43



    A BILL FOR AN ACT to amend the Indiana Code concerning insurance.

Be it enacted by the General Assembly of the State of Indiana:

    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.


     (d) "Insured" means an individual entitled to reimbursement for expenses of health care services under a policy issued or administered by an insurer.
     (e) "Insurer" means an insurance company authorized in this state to issue policies that provide reimbursement for expenses of health care services.
     (f) "Person" means an individual, an agency, a political subdivision, a partnership, a corporation, an association, or any other entity.
     (g) "Preferred provider plan" means an undertaking to enter into agreements with providers relating to terms and conditions of reimbursements for the health care services of insureds, members, or enrollees relating to the amounts to be charged to insureds, members, or enrollees for health care services.
     (h) "Provider" means an individual or entity duly licensed or legally authorized to provide health care services.
    SECTION 2. IC 27-8-11-7 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY 1, 2005]: Sec. 7. (a) This section applies to an insurer that issues or administers a policy that provides coverage for basic health care services (as defined in IC 27-13-1-4).
    (b) The department of insurance 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 an insurer; and
        (2) an insurer that performs credentialing activities.
    (c) An insurer 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 insurer receives the completed credentialing application form.
    (d) An insurer shall notify a provider concerning the status of the provider's completed credentialing application not later than:
        (1) sixty (60) days after the insurer receives the completed credentialing application form; and
        (2) every thirty (30) days after the notice is provided under subdivision (1), until the insurer makes a final credentialing determination concerning the provider.

    SECTION 3. IC 27-13-1-10.5 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY 1, 2005]: Sec. 10.5. "Credentialing" means a process through which a health maintenance organization makes

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 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.