HB636 (2007) Detail

Relative to physician credentialing under the managed care law.


CHAPTER 98

HB 636-FN – FINAL VERSION

27Mar2007… 0798h

05/10/07 1454s

2007 SESSION

07-0810

01/05

HOUSE BILL 636-FN

AN ACT relative to physician credentialing under the managed care law.

SPONSORS: Rep. McLeod, Graf 2; Rep. Nordgren, Graf 9; Rep. DeStefano, Merr 13; Rep. Pantelakos, Rock 16; Rep. Rosenwald, Hills 22; Sen. Odell, Dist 8

COMMITTEE: Commerce

AMENDED ANALYSIS

This bill allows the health care professional undergoing the formal credentialing process to provide services to patients during the process and to be reimbursed for such services upon verification of a clean credentialing record. This bill also establishes a time period within which the credentialing process is to be completed.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Explanation: Matter added to current law appears in bold italics.

Matter removed from current law appears [in brackets and struckthrough.]

Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

27Mar2007… 0798h

05/10/07 1454s

07-0810

01/05

STATE OF NEW HAMPSHIRE

In the Year of Our Lord Two Thousand Seven

AN ACT relative to physician credentialing under the managed care law.

Be it Enacted by the Senate and House of Representatives in General Court convened:

98:1 Managed Care Law; Credentialing Verification. Amend RSA 420-J:4, I to read as follows:

I. A health carrier shall:

(a) Establish written policies and procedures for credentialing verification of all health care professionals with whom the health carrier contracts and apply these standards consistently.

(b) Verify the credentials of a health care professional [before the health care professional with whom the health carrier is contracting provides health services to covered persons]. Prior to completion of credentialing verification the health carrier shall:

(1) Allow a health care provider who, at the time of submission of a clean and complete application, has a valid license from the respective state licensing board and has been credentialed by the hospital, if appropriate, to deliver health care services to covered persons when covering on-call for another health care provider who is credentialed by the carrier.

(2) Allow a health care provider to deliver health care services to covered persons when that health care provider has a valid license from the respective state licensing board and has been credentialed by the hospital, if appropriate, and who at the time of submission of a clean and complete application is credentialed by the health carrier in another state or is in the health carrier’s New Hampshire network based on employment with a particular health care entity. When a health care provider relocates or opens an additional office and the carrier requires a site visit, documentation of the new site evaluation shall be required as part of the credentialing process. The medical director of the health carrier or other designated health care professional shall have responsibility for, and shall participate in, health care professional credentialing verification.

(c) Establish a credentialing verification committee consisting of licensed physicians and other health care professionals to review credentialing verification information and supporting documents and make decisions regarding credentialing verification.

(d) Make available for review by the applying health care professional upon written request all application and credentialing verification policies and procedures.

(e) Retain records and documents relating to a health care professional’s credentialing verification process for 7 years.

(f) Keep confidential all information obtained in the credentialing verification process, except as otherwise provided by law.

(g) Notify a health care provider that a submitted credentialing application is incomplete, not later than 15 business days after receiving the credentialing application.

(h) Act upon and finalize the credentialing process within 30 calendar days for primary care physicians and 45 days for specialists of receipt of a clean and complete application. In this section, “clean and complete” means an application signed and appropriately dated by the health care provider, that includes all of the applicable information required in paragraph II and any affirmative responses on questions related to quality and clinical competence shall contain explanations satisfactory to the carrier.

(i) An applicant’s rights under this section and under RSA 420-J:8-c shall terminate upon denial of the credentialing application by the health carrier or if the applicant decides not to contract with the health carrier.

98:2 New Section; Reimbursement for Providers Waiting for Health Carrier Credentialing Verification. Amend RSA 420-J by inserting after section 8-b the following new section:

420-J:8-c Reimbursement for Providers Waiting for Health Carrier Credentialing Verification. Pursuant to RSA 420-J:4, I, health carriers issuing health benefit plans subject to this chapter shall pay claims for covered services rendered to covered persons by a health care provider who, at the time of submission of a clean and complete credentialing application, has a valid license from the respective state licensing board and has been credentialed by the hospital, if appropriate. The claim for covered services rendered by the provider applicant shall be paid at the same contracted rate as the credentialed provider:

I. When covering on-call for another health care provider who is credentialed by the carrier and billed using the name of the credentialed provider; or

II. Who, at the time of application, is credentialed by the health carrier in another state or is in the health carrier’s New Hampshire network based on employment with a particular health care entity.

98:3 Effective Date. This act shall take effect 60 days after its passage.

Approved: June 11, 2007

Effective: August 10, 2007