(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 health maintenance organization
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 health maintenance organization makes a determination that:
(1)is based on criteria established by the health maintenance
organization; and
(2)concerns whether a provider is eligible to:
(A)provide health services to an individual eligible for
coverage; and
(B)receive reimbursement for the health services;
under an agreement that is entered into between the provider and
the he
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(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 health maintenance organization
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 health maintenance organization makes a determination that:
(1) is based on criteria established by the health maintenance
organization; and
(2) concerns whether a provider is eligible to:
(A) provide health services to an individual eligible for
coverage; and
(B) receive reimbursement for the health services;
under an agreement that is entered into between the provider and
the health maintenance organization.
(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) The department shall prescribe the credentialing application
form used by the Council for Affordable Quality Healthcare (CAQH)
in electronic or paper format. The form must be used by:
(1) a provider who applies for credentialing by a health
maintenance organization; and
(2) a health maintenance organization that performs credentialing
activities.
(e) A health maintenance organization 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.
(f) A provider shall respond to the notification required under
subsection (e) not later than five (5) business days after receipt of the
notice.
(g) A health maintenance organization 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 health maintenance organization makes a final
credentialing determination concerning the provider.
(h) If the health maintenance organization fails to issue a
credentialing determination within fifteen (15) business days after
receiving a completed clean credentialing application form from a
provider, the health maintenance organization 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.
(i) Once a health maintenance organization 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 health maintenance organization shall
reimburse the provider at the rates determined by the contract between
the provider and the health maintenance organization.
(j) If a health maintenance organization does not fully credential a
provider that is provisionally credentialed under subsection (h), the
provisional credentialing is terminated on the date the health
maintenance organization notifies the provider of the adverse
credentialing determination. The health maintenance organization is
not required to reimburse for services rendered while the provider was
provisionally credentialed.