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PRINTER'S NO. 525
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
533
Session of
2019
INTRODUCED BY OWLETT, PICKETT, KAUFER, RYAN, MILLARD, SIMMONS,
MENTZER, GREGORY, ROTHMAN, HEFFLEY, JAMES, LAWRENCE, DeLUCA
AND JONES, FEBRUARY 19, 2019
REFERRED TO COMMITTEE ON HEALTH, FEBRUARY 19, 2019
AN ACT
Providing for the use of certain credentialing applications and
for credentialing requirements for health insurers; imposing
penalties; and conferring powers and imposing duties on the
Insurance Department.
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.
"Credentialing." The process of assessing and validating the
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qualifications of a health care practitioner, including, but not
limited to, an evaluation of licensure status, education,
training, experience, competence and professional judgment.
"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. ยง 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 in section 1903(m)(1)(a) of the
Social Security Act, 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
Act.
(iii) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations).
(iv) 40 Pa.C.S. Ch. 63 (relating to professional
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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
or other process as designated by the Insurance Department and
all required information is provided.
Section 4. Credentialing.
The health insurer shall issue a credentialing determination
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within 45 days after receiving a complete CAQH credentialing
application.
Section 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. No health insurer shall be subject to an
administrative penalty based on a health care practitioner's
failure to use or complete a CAQH credentialing application.
Section 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 7. Rules and regulations.
The Insurance Department shall promulgate rules and
regulations to administer and enforce this act.
Section 8. Repeals.
All acts and parts of acts are repealed insofar as they are
inconsistent with this act.
Section 9. Effective date.
This act shall take effect in 180 days.
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