§ 12-15-11-9 — Credentialing; provisional; application form; notification; retroactive reimbursement; adverse determination; appeal

Indiana § 12-15-11-9

• Jurisdiction: Indiana
• Art. 15: MEDICAID
• Ch. 11: Provider Agreements and Competitive Bidding

Text

(a) As used in this section, "clean
credentialing application" means an application for network
participation that:
(1) is submitted by a provider under this section;
(2) does not contain an error; and
(3) may be processed by the managed care organization or
contractor of the office without returning the application to the
provider for a revision or clarification.
(b) As used in this section, "credentialing" means a process by
which a managed care organization or contractor of the office makes
a determination that:
(1) is based on criteria established by the managed care
organization or contractor of the office; and
(2) concerns whether a provider is eligible to:
(A) provide health services to an individual eligible for
Medicaid services; and
(B) receive reimbursement for the health services;
under an agreement that is entered into between the provider and
managed care organization or contractor of the office.
(c) As used in this section, "unclean credentialing application"
means an application for network participation that:
(1) is submitted by a provider under this section;
(2) contains at least one (1) error; and
(3) must be returned to the provider to correct the error.
(d) This section applies to a managed care organization or
contractor of the office.
(e) If the office or managed care organization issues a provisional
credential to a provider under subsection (j), the office or managed care
organization shall:
(1) issue a final credentialing determination not later than sixty
(60) calendar days after the date in which the provider was
provisionally credentialed; and
(2) except as provided in subsection (l), provide retroactive
reimbursement under subsection (k).
(f) The office shall prescribe the credentialing application form used
by the Council for Affordable Quality Healthcare in electronic or paper
format, which must be used by:
(1) a provider who applies for credentialing by a managed care
organization or contractor of the office; and
(2) a managed care organization or contractor of the office that
performs credentialing activities.
(g) A managed care organization or contractor of the office shall
notify a provider concerning a deficiency on a completed unclean
credentialing application form submitted by the provider not later than
five (5) business days after the entity receives the completed unclean
credentialing application form. A notice described in this subsection
must:
(1) provide a description of the deficiency; and
(2) state the reason why the application was determined to be an
unclean credentialing application.
(h) A provider shall respond to the notification required under
subsection (g) not later than five (5) business days after receipt of the
notice.
(i) A managed care organization or contractor of the office shall
notify a provider concerning the status of the provider's completed
clean credentialing application when:
(1) the provider is provisionally credentialed; and
(2) the entity makes a final credentialing determination
concerning the provider.
(j) If the managed care organization or contractor of the office fails
to issue a credentialing determination within fifteen (15) business days
after receiving a completed clean credentialing application form from
a provider, the managed care organization or contractor of the office
shall provisionally credential the provider in accordance with the
standards and guidelines governing provisional credentialing from the
National Committee for Quality Assurance or its successor
organization. The provisional credentialing license is valid until a
determination is made on the credentialing application of the provider.
(k) Once a managed care organization or contractor of the office
fully credentials a provider that holds provisional credentialing and a
network provider agreement has been executed, then reimbursement
payments under the contract shall be paid retroactive to the date the
provider was provisionally credentialed. The managed care
organization or contractor of the office shall reimburse the provider at
the rates determined by the contract between the provider and the:
(1) managed care organization; or
(2) contractor of the office.
(l) If a managed care organization or contractor of the office does
not fully credential a provider that is provisionally credentialed under
subsection (j), the provisional credentialing is terminated on the date
the managed care organization or contractor of the office notifies the
provider of the adverse credentialing determination. The managed care
organization or contractor of the office is not required to reimburse for
services rendered while the provider was provisionally credentialed.
(m) A managed care organization or contractor of the office may not
require additional credentialing requirements in order to participate in
a managed care organization's network. However, a contractor may
collect additional information from the provider in order to complete
a contract or provider agreement.
(n) A managed care organization or contractor of the office is not
required to contract with a provider.
(o) A managed care organization or contractor of the office shall:
(1) send representatives to meetings and participate in the
credentialing process as determined by the office; and
(2) not require additional credentialing information from a
provider if a non-network credentialed provider is used.
(p) Except when a provider is no longer enrolled with the office, a
credential acquired under this chapter is valid until recredentialing is
required.
(q) An adverse action under this section is subject to IC 4-21.5.
(r) The office may adopt rules under IC 4-22-2 to implement this
section.

Legislative History

As added by P.L.195-2018, SEC.5. Amended by P.L.32-2021, SEC.31; P.L.190-2023, SEC.3; P.L.17-2024, SEC.2.