20-3451. Definitions In this chapter, unless the context otherwise requires: 1. " Applicant" means a provider that submits a credentialing application to a health insurer to become a participating provider in the health insurer’s network. 2. " Application" means an applicant’s initial application to be credentialed as a participating provider. 3. " Credentialing" means to […]
20-3452. Requirements for electronic application submission A. A health insurer shall establish a process for the electronic submission of a credentialing application. On or before December 31, 2019, the health insurers shall adopt and implement a standard application. B. On or before December 31, 2019, to the greatest extent possible, a health insurer shall establish […]
20-3453. Credentialing; loading; timelines; exception A. Except as provided in subsection C of this section, the health insurer shall conclude the process of credentialing and loading the applicant’s information into the health insurer’s billing system within one hundred calendar days after the date the health insurer receives a complete application. B. A health insurer shall […]
20-3454. Acknowledgement of receipt of an application; notification of incomplete applications A. A health insurer shall provide written or electronic acknowledgement to an applicant within seven calendar days after the health insurer’s receipt of the applicant’s application. The applicant shall include in the application a contact name, telephone number and e-mail address to address discrepancies […]
20-3455. Reported discrepancies; corrective action A health insurer shall take reasonable steps to correct discrepancies in the provider or network plan directory within thirty calendar days after receiving a written or electronic report of the discrepancy from a participating provider. A participating provider shall notify a health insurer of any change in the provider’s name, […]
20-3456. Covered services; claims A health insurer may not deny a claim for a covered service provided to a subscriber by a participating provider who has a fully executed contract with a network plan if the covered services are provided after the date of approval of the credentialing application.
20-3457. Availability of credentialing information; policies A. A health insurer shall make the following nonproprietary information available to all applicants for credentialing and shall post the information on its website: 1. The applicable credentialing policies and procedures. 2. A list of all the information required to be included in an application. 3. A checklist of […]
20-3458. Recredentialing A. A health insurer or its designee may recredential participating providers at least once every thirty-six months and more frequently if required by federal or state law or the health insurer’s accreditation standards, or if permitted by the health insurer’s contract with the participating provider. Nothing in this section shall affect the contract […]
20-3459. Civil immunity; enforcement; civil penalty A. A health insurer that complies in good faith with the requirements of this chapter is immune from civil liability for the purposes of reviewing and approving a credentialing application. B. The director shall enforce this chapter. A health insurer that fails to comply with this chapter or with […]
