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2023 SESSION
23102318DBe it enacted by the General Assembly of Virginia:
1. That § 38.2-3407.10:1 of the Code of Virginia is amended and reenacted as follows:
§ 38.2-3407.10:1. Processing of new provider applications and reimbursement for services rendered during pendency of a participating provider's credentialing application.
A. As used in this section:
"Carrier" means an entity subject to the insurance laws and regulations of the Commonwealth and subject to the jurisdiction of the Commission that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services or mental health services, including an insurer licensed to sell accident and sickness insurance, a health maintenance organization, a health services plan, or any other entity providing a plan of health insurance, health benefits, health care services, or mental health services.
"Covered person" means a policyholder, subscriber, enrollee, participant, or other individual covered by a health benefit plan.
"Health benefit plan" means a policy, contract, certificate, or agreement offered by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
"Mental health professional" has the meaning ascribed thereto in § 54.1-2400.1.
"Mental health services" means benefits with respect to items or services provided by mental health professionals for mental health conditions as defined in § 37.2-100 that are covered under the terms of a health benefit plan and may include treatment of substance abuse.
"Network" means a group of participating providers who provide health care services under the carrier's health benefit plan that requires or creates incentives for a covered person to use the participating providers.
"New provider applicant" means a physician, mental health professional, or other provider who has submitted a completed credentialing application to a carrier.
"Other provider" means a person, corporation, facility, or institution licensed by the Commonwealth under Title 32.1 or 54.1 to provide health care or professional health-related services on a fee basis.
"Participating mental health professional" means a mental health professional who is managed, under contract with, or employed by a carrier and who has agreed to provide health care services to covered persons with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier.
"Participating other provider" means an other provider who is managed, under contract with, or employed by a carrier and who has agreed to provide such health care or professional services to covered persons with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier.
"Participating physician" means a physician who is managed, under contract with, or employed by a carrier and who has agreed to provide health care services or mental health services to covered persons with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier.
"Participating provider" means a participating physician, participating mental health professional, or participating other provider.
"Physician" means a doctor of medicine or osteopathic medicine holding an active license from the Board of Medicine.
B. A carrier that credentials the physicians, mental health
professionals, or other providers in its network shall establish reasonable
protocols and procedures for processing of
new provider credentialing applications and
reimbursing new provider applicants, within 30 days of
being credentialed by the carrier, for health care services
or mental health services provided to covered persons during the period in
which the applicant's completed credentialing application is pending. At a
minimum, the protocols and procedures shall:
1. Apply only if the
new provider applicant's credentialing application is approved by Require the carrier to approve or deny new provider credentialing
applications within 60 days of receiving a completed
application; and
2. Permit
reimbursement to a new provider applicant Require payment no later than 30
days after the carrier
approves the new provider credentialing application for
services rendered from the date the new provider applicant's completed
credentialing application is received provided to the carrier for
consideration by the carrier;
3. Notwithstanding
the provisions of subdivision 1 or 4, if.
C. If
the carrier accepts applications through an online credentialing system, require
the carrier shall be required to recognize
notification to a new provider applicant through the online credentialing
system that the provider has submitted and attested to the application as
notice by the carrier that the application is received and
complete. If the carrier does not accept applications
through an online credentialing system, the carrier shall be required, within
10 days of receiving an application, to provide notification to the new
provider applicant either by mail or electronic mail, as selected by the
applicant, that the application was received
and is complete;
4. D. The reimbursement provisions of this section
shall:
1. Apply only if the new provider applicant's credentialing application is approved by the carrier;
2. Apply only if a contractual relationship exists between the carrier and the new provider applicant or entity for whom the new provider applicant is employed or engaged; and
5. 3. Require
that any reimbursement be paid at the in-network rate that the new provider
applicant would have received had he been, at the time the covered health care
services or mental health services were
provided, a credentialed participating provider in the network for the
applicable health benefit plan.
C. E. Nothing in this section shall
require reimbursement of the new provider applicant-rendered services that are
not benefits or services covered by the carrier's health benefit plan.
D. F. Nothing in this section
requires a carrier to pay reimbursement at the contracted in-network rate for
any covered health care services or mental health services provided by the new
provider applicant if the new provider applicant's credentialing application is
not approved or the carrier is otherwise not willing to contract with the new
provider applicant.
E. G. Payments made or retroactive
denials of payments made under this section shall be governed by §
38.2-3407.15.
F. H. If a payment is made by the
carrier to a new provider applicant or any entity that employs or engages such
new provider applicant under this section for a covered service, the patient
shall only be responsible for any coinsurance, copayments, or deductibles
permitted under the insurance contract with the carrier or participating
provider agreement with the physician, mental health professional, or other
provider. If the new provider applicant is not credentialed by the carrier, the
new provider applicant or any entity that employs or engages such physician,
mental health professional, or other provider shall not collect any amount from
the patient for health care services or mental health services provided from
the date the completed credentialing application was submitted to the carrier
until the applicant received notification from the carrier that credentialing
was denied.
G. I. New provider applicants, in
order to submit claims to the carrier pursuant to this section, shall provide
written or electronic notice to covered persons in advance of treatment that
they have submitted a credentialing application to the carrier of the covered
person, stating that the carrier is in the process of obtaining and verifying
the following pursuant to credentialing regulations:
"Notice of Provider credentialing and re-credentialing.
Your health insurance carrier is required to establish and maintain a comprehensive credentialing verification program to ensure that its physicians, mental health professionals, and other providers meet the minimum standards of professional licensure or certification. Written supporting documentation for (i) physicians, (ii) mental health professionals who have completed their residency or fellowship requirements for their specialty area more than 12 months prior to the credentialing decision, or (iii) other providers shall include:
1. Current valid license and history of licensure or certification;
2. Status of hospital privileges, if applicable;
3. Valid U.S. Drug Enforcement Administration certificate, if applicable;
4. Information from the National Practitioner Data Bank, as available;
5. Education and training, including postgraduate training, if applicable;
6. Specialty board certification status, if applicable;
7. Practice or work history covering at least the past five years; and
8. Current, adequate malpractice insurance and malpractice history covering at least the past five years.
Your health insurance carrier is in the process of obtaining and verifying the above information in order to determine if your physician, mental health professional, or other provider will be credentialed or not."
H. J. The provisions of this
section shall not apply to coverages issued by a Medicare Advantage plan, but
shall apply to health maintenance organizations that issue coverage pursuant to
Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid).
I. K. The Commission shall have no
jurisdiction to adjudicate individual controversies arising out of this
section.