HSB 502 (LSB 5349YC (2) 91)

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.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  Section 514F.6, Code 2026, is amended to read as follows:
   514F.6  Credentialing.
   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 health care professional during the credentialing period, once the physician, advanced registered nurse practitioner, or physician assistant health care professional is credentialed.
   2.  Credentialing process.
   a.  A health insurer shall respond to a physician, advanced registered nurse practitioner, or physician assistant’s health care professional’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 health care professional’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 health care professional.
   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.  a.  “Clean claim” means the same as defined in section 507B.4A, subsection 2, paragraph “b”.
   c.  b.  “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 health care professional 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 health care professional and the health insurer.
   d.  c.  “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 health care professional’s application for credentialing and approval of that application by the health insurer.
   d.  “Health care professional” means the same as defined in section 514J.102.
   e.  “Physician” means a licensed doctor of medicine and surgery or a licensed doctor of osteopathic medicine and surgery.
   f.  “Physician assistant” means the same as defined in section 148C.1.
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. Current law requires a health insurer to respond to a physician, advanced registered nurse practitioner, or physician assistant’s request for credentialing within 56 calendar days, and, if the credentialing request is denied, to provide a reason for the denial. The bill expands the health insurer’s obligation to include all health care professionals. “Health care professional” is defined in the bill as a physician or other health care practitioner licensed, accredited, registered, or certified to perform specified health care services consistent with state law.