A01387
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
125
Session of
2017
INTRODUCED BY BAKER, BARRAR, CUTLER, D. COSTA, A. HARRIS,
CALTAGIRONE, MENTZER, JAMES, MILLARD, PHILLIPS-HILL,
ZIMMERMAN, WARD, LAWRENCE, PICKETT AND GABLER,
JANUARY 23, 2017
REFERRED TO COMMITTEE ON HEALTH, JANUARY 23, 2017
AN ACT
Providing for the use of certain credentialing applications, and
for credentialing requirements for health insurers and for
protections for enrollees of health insurers; imposing
penalties; and conferring powers and imposing duties on the
Insurance Department and Department of Health.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be known and may be cited as the Health Care
Practitioner Credentialing Act.
Section 2. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"CAQH." The Council for Affordable Quality Healthcare.
"CAQH credentialing application." The application used to
collect the credentials data commonly requested by health
insurers for purposes of credentialing.
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"Credentialing." The process of assessing and validating the
qualifications of a health care practitioner, including, but not
limited to, an evaluation of licensure status, education,
training, experience, competence and professional judgment.
"Enrollee." Any policyholder, subscriber, covered person,
covered dependent, spouse or other person who is entitled to
receive health care benefits from a health insurer.
"Federally qualified health center." A federally qualified
health center as defined in section 1905(l)(2)(B) of the Social
Security Act (49 Stat. 620, 42 U.S.C. § 1396d(l)(2)(B)), or a
federally qualified health center look-alike, that is a
participating provider with the Department of Human Services
under the act of June 13, 1967 (P.L.31, No.21), known as the
Human Services Code.
"Health care practitioner." As defined under section 103 of
the act of July 19, 1979 (P.L.130, No.48), known as the Health
Care Facilities Act. The term shall include a health care
practitioner at a federally qualified health center.
"Health insurer." As follows:
(1) An entity that contracts or offers to contract to
provide, deliver, arrange for, pay for or reimburse any of
the costs of health care services in exchange for a premium,
including, but not limited to, a Medicaid managed care
organization as defined under the act of June 13, 1967
(P.L.31, No.21), known as the Human Services Code, and an
entity licensed under any of the following:
(i) The act of May 17, 1921 (P.L.682, No.284), known
as The Insurance Company Law of 1921.
(ii) The act of December 29, 1972 (P.L.1701,
No.364), known as the Health Maintenance Organization
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Act.
(iii) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations).
(iv) 40 Pa.C.S. Ch. 63 (relating to professional
health services plan corporations).
(2) The term shall not include the following types of
insurance, or any combination thereof:
(i) Accident only.
(ii) Fixed indemnity.
(iii) Limited benefit.
(iv) Credit.
(v) Dental.
(vi) Vision.
(vii) Specified disease.
(viii) Medicare supplement.
(ix) Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS) supplement.
(x) Long-term care or disability income.
(xi) Workers' compensation.
(xii) Automobile medical payment insurance.
Section 3. Utilization of CAQH.
All health insurers licensed to do business in this
Commonwealth shall be required to accept the CAQH credentialing
application or other form designated by the Insurance Department
so long as the form is nationally recognized as an appropriate
credentialing application when submitted by a health care
practitioner for participation in the health insurer's provider
panel. All health care practitioners shall use the CAQH or other
designated form. An application shall be considered complete if
the application is submitted through the CAQH electronic process
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or other process as designated by the Insurance Department and
all required information is provided.
Section 4. Credentialing.
(a) Provisional credentialing.--If a The health insurer
fails to shall issue a credentialing determination within 30 45
days after receiving a complete CAQH credentialing application,
the health care practitioner shall be deemed provisionally
credentialed. A health care practitioner shall be eligible for
provisional credentialing if:
(1) the health care practitioner has applied to
participate in the health insurer's provider panel for the
first time; or
(2) the health care practitioner is a member of a
provider group that is a participating provider.
(b) Adverse credentialing decision.--If a health insurer
makes an adverse credentialing determination or otherwise
rejects an applicant's application, the applicant shall no
longer be eligible for provisional status, and any provisional
status previously granted shall be terminated effective as of
the date the applicant is provided notice of adverse
determination or rejection.
(c) Services rendered under provisional credentialing.--A
health insurer shall provide coverage and reimbursement for
services rendered by an applicant granted provisional status
under the same terms as are applicable to participating health
care practitioners in the applicant's provider group.
Practitioners granted provisional status and not practicing
within a group shall be reimbursed according to the health
insurer's standard fee schedule. Upon an affirmative
credentialing decision, payments pursuant to the contract shall
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be retroactive to the date of the provisional credentialing.
Only a negative credentialing decision due to submission of
fraudulent information from the applicant shall relieve a health
plan from retroactive payment for services provided during a
provisional credentialing period.
Section 5. Enrollee protections.
A health care practitioner with provisional status may not
hold an enrollee of the health insurer liable for the cost of
any covered services provided to the enrollee during the time
period that the applicant has provisional status, except for any
deductible, copayment or coinsurance amount owed by the
enrollee. A health care practitioner with provisional status
shall notify an enrollee of the health insurer, at the time
services are provided, that:
(1) the health care practitioner is not a participating
provider;
(2) the health care practitioner has applied to become a
participating provider;
(3) the health insurer has not completed the assessment
of the qualifications of the health care practitioner to
provide services as a participating provider; and
(4) any covered services rendered by the health care
practitioner must be reimbursed by the health insurer at the
participating provider rate.
Section 6 5. Penalty.
The Insurance Department shall assess an administrative
penalty on a health insurer for a failure to utilize CAQH, or
other designated application, or for intentionally and routinely
failing to complete the credentialing process according to
section 4(a) or for failing to reimburse applicants granted
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provisional status in accordance with this act 4. No health
insurer shall be subject to administrative penalty based on a
health care practitioner's failure to use or complete a CAQH
credentialing application.
Section 7 6. Rights.
Nothing in this act shall be construed to guarantee the
rights of a health care practitioner to participate in any
health insurer network in this Commonwealth nor require a health
insurer to accept any willing health care provider to an
insurance network.
Section 8 7. Rules and regulations.
The Department of Health and the Insurance Department shall
promulgate rules and regulations to administer and enforce this
act.
Section 9 8. Repeals.
All acts and parts of acts are repealed insofar as they are
inconsistent with this act.
Section 10 9. Effective date.
This act shall take effect in 180 days.
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