HF 556 (LSB 1798YH (2) 91)

HOUSE FILE 556

BY  A. MEYER

A BILL FOR

An Act relating to health insurers’ credentialing process.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  Section 514F.6, Code 2025, is amended to read as follows:
   514F.6  Credentialing —— retrospective payment.
   1.  Retrospective payment.  The commissioner shall adopt rules to provide for the retrospective payment of clean claims for covered services provided by a physician, advanced registered nurse practitioner, or physician assistant during the credentialing period, once the physician, advanced registered nurse practitioner, or physician assistant is credentialed.
   2.  Credentialing process.
   a.  A health insurer shall respond to a physician, advanced registered nurse practitioner, or physician assistant’s request for credentialing within fifty-six calendar days from the date of the request.
   b.  If a physician’s, advanced registered nurse practitioner’s, or physician assistant’s request for credentialing is denied by the health insurer, the health insurer shall provide a reason for the denial, in writing, to the physician, advanced registered nurse practitioner, or physician assistant.
   c.  A physician, advanced registered nurse practitioner, or physician assistant who is denied credentialing shall have an opportunity, after an internal appeal, to appeal the denial to the insurance division. In addition to any other grounds for an appeal, network adequacy shall constitute grounds for a physician, advanced nurse practitioner, or physician assistant to appeal.
   2.  3.  Definitions.  For purposes of this section:
   a.  “Advanced registered nurse practitioner” means a person currently licensed as a registered nurse under chapter 152 or 152E who is licensed by the board of nursing as an advanced registered nurse practitioner.
   b.  “Clean claim” means the same as defined in section 507B.4A, subsection 2, paragraph “b”.
   c.  “Credentialing” means a process through which a health insurer makes a determination based on criteria established by the health insurer concerning whether a physician, advanced registered nurse practitioner, or physician assistant is eligible to provide health care services to an insured and to receive reimbursement for the health care services provided under an agreement entered into between the physician, advanced registered nurse practitioner, or physician assistant and the health insurer.
   d.  “Credentialing period” means the time period between the health insurer’s receipt of a physician’s, advanced registered nurse practitioner’s, or physician assistant’s application for credentialing and approval of that application by the health insurer.
   e.  “Physician” means a licensed doctor of medicine and surgery or a licensed doctor of osteopathic medicine and surgery.
   f.  “Physician assistant” means a person who is licensed to practice as a physician assistant under the supervision of one or more physicians. 
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to health insurers’ credentialing process. Under the bill, a health insurer (insurer) shall respond to a physician, advanced registered nurse practitioner, or physician assistant’s request for credentialing within 56 calendar days. If a request for credentialing is denied by the insurer, the insurer shall provide a reason for the denial to the physician, advanced registered nurse practitioner, or physician assistant. The physician, advanced registered nurse practitioner, or physician assistant shall have an opportunity, after an internal appeal, to appeal the denial to the insurance division. In addition to any other grounds for an appeal, network adequacy shall constitute grounds for an appeal.