House
File
875
-
Introduced
HOUSE
FILE
875
BY
COMMITTEE
ON
COMMERCE
(SUCCESSOR
TO
HF
556)
A
BILL
FOR
An
Act
relating
to
health
insurers’
credentialing
process.
1
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
2
TLSB
1798HV
(4)
91
nls/ko
H.F.
875
Section
1.
Section
514F.6,
Code
2025,
is
amended
to
read
as
1
follows:
2
514F.6
Credentialing
——
retrospective
payment
.
3
1.
Retrospective
payment.
The
commissioner
shall
adopt
4
rules
to
provide
for
the
retrospective
payment
of
clean
5
claims
for
covered
services
provided
by
a
physician,
advanced
6
registered
nurse
practitioner,
or
physician
assistant
during
7
the
credentialing
period,
once
the
physician,
advanced
8
registered
nurse
practitioner,
or
physician
assistant
is
9
credentialed.
10
2.
Credentialing
process.
11
a.
A
health
insurer
shall
respond
to
a
physician,
advanced
12
registered
nurse
practitioner,
or
physician
assistant’s
request
13
for
credentialing
within
fifty-six
calendar
days
from
the
date
14
of
the
request.
15
b.
If
a
physician’s,
advanced
registered
nurse
16
practitioner’s,
or
physician
assistant’s
request
for
17
credentialing
is
denied
by
the
health
insurer,
the
health
18
insurer
shall
provide
a
reason
for
the
denial,
in
writing,
19
to
the
physician,
advanced
registered
nurse
practitioner,
or
20
physician
assistant.
21
2.
3.
Definitions.
For
purposes
of
this
section
:
22
a.
“Advanced
registered
nurse
practitioner”
means
a
person
23
currently
licensed
as
a
registered
nurse
under
chapter
152
or
24
152E
who
is
licensed
by
the
board
of
nursing
as
an
advanced
25
registered
nurse
practitioner.
26
b.
“Clean
claim”
means
the
same
as
defined
in
section
27
507B.4A,
subsection
2
,
paragraph
“b”
.
28
c.
“Credentialing”
means
a
process
through
which
a
health
29
insurer
makes
a
determination
based
on
criteria
established
by
30
the
health
insurer
concerning
whether
a
physician,
advanced
31
registered
nurse
practitioner,
or
physician
assistant
is
32
eligible
to
provide
health
care
services
to
an
insured
and
to
33
receive
reimbursement
for
the
health
care
services
provided
34
under
an
agreement
entered
into
between
the
physician,
advanced
35
-1-
LSB
1798HV
(4)
91
nls/ko
1/
2
H.F.
875
registered
nurse
practitioner,
or
physician
assistant
and
the
1
health
insurer.
2
d.
“Credentialing
period”
means
the
time
period
between
the
3
health
insurer’s
receipt
of
a
physician’s,
advanced
registered
4
nurse
practitioner’s,
or
physician
assistant’s
application
for
5
credentialing
and
approval
of
that
application
by
the
health
6
insurer.
7
e.
“Physician”
means
a
licensed
doctor
of
medicine
and
8
surgery
or
a
licensed
doctor
of
osteopathic
medicine
and
9
surgery.
10
f.
“Physician
assistant”
means
the
same
as
defined
in
11
section
148C.1.
12
EXPLANATION
13
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
14
the
explanation’s
substance
by
the
members
of
the
general
assembly.
15
This
bill
relates
to
health
insurers’
credentialing
process.
16
Under
the
bill,
a
health
insurer
(insurer)
shall
respond
to
a
17
physician,
advanced
registered
nurse
practitioner,
or
physician
18
assistant’s
request
for
credentialing
within
56
calendar
days.
19
If
a
request
for
credentialing
is
denied
by
the
insurer,
the
20
insurer
shall
provide
a
reason
for
the
denial
to
the
physician,
21
advanced
registered
nurse
practitioner,
or
physician
assistant.
22
-2-
LSB
1798HV
(4)
91
nls/ko
2/
2