This text of Iowa § 514F.6 (Credentialing) is published on Counsel Stack Legal Research, covering Iowa primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
1.Retrospective payment. The commissioner shall adopt rules to provide for the
retrospectivepaymentofcleanclaimsforcoveredservicesprovidedbyaphysician, advanced
3 UTILIZATION AND COST CONTROL, §514F.7
registered nurse practitioner, or physician assistant during the credentialing period, once
the physician, advanced registered nurse practitioner, or physician assistant is credentialed.
2.Credentialing process.
a.A health insurer shall respond to a physician, advanced registered nurse practitioner,
or physician assistant’s request for credentialing within fifty-six calendar days from the date
of the request.
b.If a physician’s, advanced registered nurse practitioner’s, or physician assistant’s
request for credentialing is denied by the health insurer, the health insurer shall provide a
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1. Retrospective payment. The commissioner shall adopt rules to provide for the
retrospectivepaymentofcleanclaimsforcoveredservicesprovidedbyaphysician, advanced
3 UTILIZATION AND COST CONTROL, §514F.7
registered nurse practitioner, or physician assistant during the credentialing period, once
the physician, advanced registered nurse practitioner, or physician assistant is credentialed.
2. Credentialing process.
a. A health insurer shall respond to a physician, advanced registered nurse practitioner,
or physician assistant’s request for credentialing within fifty-six calendar days from the date
of the request.
b. If a physician’s, advanced registered nurse practitioner’s, or physician assistant’s
request for credentialing is denied by the health insurer, the health insurer shall provide a
reason for the denial, in writing, to the physician, advanced registered nurse practitioner, or
physician assistant.
3. Definitions. For purposes of this section:
a. “Advanced registered nurse practitioner” means a person currently licensed as a
registered nurse under chapter 152 or 152E who is licensed by the board of nursing as an
advanced registered nurse practitioner.
b. “Clean claim” means the same as defined in section 507B.4A, subsection 2, paragraph
“b”.
c. “Credentialing”meansaprocessthroughwhichahealthinsurermakesadetermination
based on criteria established by the health insurer concerning whether a physician, advanced
registered nurse practitioner, or physician assistant is eligible to provide health care services
to an insured and to receive reimbursement for the health care services provided under an
agreement entered into between the physician, advanced registered nurse practitioner, or
physician assistant and the health insurer.
d. “Credentialing period” means the time period between the health insurer’s receipt of a
physician’s, advanced registered nurse practitioner’s, or physician assistant’s application for
credentialing and approval of that application by the health insurer.
e. “Physician” means a licensed doctor of medicine and surgery or a licensed doctor of
osteopathic medicine and surgery.
f. “Physician assistant” means the same as defined in section 148C.1.