House
Study
Bill
502
-
Introduced
HOUSE
FILE
_____
BY
(PROPOSED
COMMITTEE
ON
HEALTH
AND
HUMAN
SERVICES
BILL
BY
CHAIRPERSON
HARRIS)
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
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Section
1.
Section
514F.6,
Code
2026,
is
amended
to
read
as
1
follows:
2
514F.6
Credentialing.
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
health
7
care
professional
during
the
credentialing
period,
once
the
8
physician,
advanced
registered
nurse
practitioner,
or
physician
9
assistant
health
care
professional
is
credentialed.
10
2.
Credentialing
process.
11
a.
A
health
insurer
shall
respond
to
a
physician,
advanced
12
registered
nurse
practitioner,
or
physician
assistant’s
health
13
care
professional’s
request
for
credentialing
within
fifty-six
14
calendar
days
from
the
date
of
the
request.
15
b.
If
a
physician’s,
advanced
registered
nurse
16
practitioner’s,
or
physician
assistant’s
health
care
17
professional’s
request
for
credentialing
is
denied
by
the
18
health
insurer,
the
health
insurer
shall
provide
a
reason
for
19
the
denial,
in
writing,
to
the
physician,
advanced
registered
20
nurse
practitioner,
or
physician
assistant
health
care
21
professional
.
22
3.
Definitions.
For
purposes
of
this
section
:
23
a.
“Advanced
registered
nurse
practitioner”
means
a
person
24
currently
licensed
as
a
registered
nurse
under
chapter
152
or
25
152E
who
is
licensed
by
the
board
of
nursing
as
an
advanced
26
registered
nurse
practitioner.
27
b.
a.
“Clean
claim”
means
the
same
as
defined
in
section
28
507B.4A,
subsection
2
,
paragraph
“b”
.
29
c.
b.
“Credentialing”
means
a
process
through
which
30
a
health
insurer
makes
a
determination
based
on
criteria
31
established
by
the
health
insurer
concerning
whether
a
32
physician,
advanced
registered
nurse
practitioner,
or
physician
33
assistant
health
care
professional
is
eligible
to
provide
34
health
care
services
to
an
insured
and
to
receive
reimbursement
35
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H.F.
_____
for
the
health
care
services
provided
under
an
agreement
1
entered
into
between
the
physician,
advanced
registered
nurse
2
practitioner,
or
physician
assistant
health
care
professional
3
and
the
health
insurer.
4
d.
c.
“Credentialing
period”
means
the
time
period
between
5
the
health
insurer’s
receipt
of
a
physician’s,
advanced
6
registered
nurse
practitioner’s,
or
physician
assistant’s
7
health
care
professional’s
application
for
credentialing
and
8
approval
of
that
application
by
the
health
insurer.
9
d.
“Health
care
professional”
means
the
same
as
defined
in
10
section
514J.102.
11
e.
“Physician”
means
a
licensed
doctor
of
medicine
and
12
surgery
or
a
licensed
doctor
of
osteopathic
medicine
and
13
surgery.
14
f.
“Physician
assistant”
means
the
same
as
defined
in
15
section
148C.1
.
16
EXPLANATION
17
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
18
the
explanation’s
substance
by
the
members
of
the
general
assembly.
19
This
bill
relates
to
health
insurers’
credentialing
20
process.
Current
law
requires
a
health
insurer
to
respond
to
a
21
physician,
advanced
registered
nurse
practitioner,
or
physician
22
assistant’s
request
for
credentialing
within
56
calendar
days,
23
and,
if
the
credentialing
request
is
denied,
to
provide
a
24
reason
for
the
denial.
The
bill
expands
the
health
insurer’s
25
obligation
to
include
all
health
care
professionals.
“Health
26
care
professional”
is
defined
in
the
bill
as
a
physician
27
or
other
health
care
practitioner
licensed,
accredited,
28
registered,
or
certified
to
perform
specified
health
care
29
services
consistent
with
state
law.
30
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