§ 27-41-87. Healthcare provider credentialing.
(a) For applications received on or after January 1, 2018, a healthcare entity or health
plan operating in the state shall be required to issue a decision regarding the credentialing
of a healthcare provider as soon as practicable, but no later than forty-five (45)
calendar days after the date of receipt of a complete credentialing application.
(b) For minor changes to the demographic information of an individual healthcare provider
who is already credentialed with a particular healthcare entity or health plan, the
healthcare entity or health plan shall complete the change within seven (7) business
days of receipt of the healthcare provider's request. Minor changes to demographic
information requested by individual providers shall be submitted in the time frame,
and manner required by the healthcare entity or health plan, and shall include all
supporting documentation required by the particular healthcare entity or health plan.
For purposes of this section, minor changes to the information profile of a healthcare
provider shall include, but not be limited to, changes of address and changes to a
healthcare provider's tax identification number.
(c) Each healthcare entity or health plan shall establish a written standard defining
what elements constitute a complete credentialing application and shall distribute
this standard with the written version of the credentialing application and make the
standard available on the healthcare entity's or health plan's website.
(d) Each healthcare entity or health plan shall respond to inquiries by the applicant
regarding the status of an application.
(1) Each healthcare entity or health plan shall provide the applicant with automated application
status updates, at least once every fifteen (15) calendar days, informing the applicant
of any missing application materials until the application is deemed complete;
(2) Each healthcare entity or health plan shall inform the applicant within five (5) business
days that the credentialing application is complete; and
(3) If the healthcare entity or health plan denies a credentialing application, the healthcare
entity or health plan shall notify the healthcare provider in writing and shall provide
the healthcare provider with any and all reasons for denying the credentialing application.
(e) The effective date for billing privileges for healthcare providers under a particular
healthcare entity or health plan shall be the next business day following the date
of approval of the credentialing application.
(f) For applications received from resident graduates on or after January 1, 2018, a healthcare
entity or health plan shall offer a transitional or conditional approval process such
that a resident graduate who has submitted an otherwise complete application and met
all other criteria, may be conditionally approved, effective upon successful graduation
from the training program.
(g) For the purposes of this section, the following definitions apply:
(1) "Complete credentialing application� means all the requested material has been submitted.
(2) "Date of receipt� means the date the healthcare entity or health plan receives the
completed credentialing application whether via electronic submission or as a paper
application.
(3) "Healthcare entity� means a licensed insurance company or nonprofit hospital or medical
or dental service corporation or plan or health maintenance organization, or a contractor
as defined in § 23-17.13-2 [repealed] that operates a health plan.
(4) "Healthcare provider� means a healthcare professional.
(5) "Health plan� means a plan operated by a healthcare entity that provides for the delivery
of healthcare services to persons enrolled in those plans through:
(i) Arrangements with selected providers to furnish healthcare services; and
(ii) Financial incentives for persons enrolled in the plan to use the participating providers
and procedures provided for by the health plan.