Introduced by Representatives Martin of Springfield, Donahue of Northfield, Emmons of Springfield, Fisher of Lincoln, Frank of Underhill, French of Randolph, Haas of Rochester, Koch of Barre Town, McAllister of Highgate, Niquette of Colchester, Pellett of Chester, Pugh of S. Burlington and Shand of Weathersfield
Subject: Uniform credentialing; providers; insurance companies
Statement of purpose: This bill proposes to require BISHCA to impose uniform requirements and forms for insurance companies to credential providers.
AN ACT RELATING TO UNIFORM PROVIDER CREDENTIALING
It is hereby enacted by the General Assembly of the State of Vermont:
Sec. 1. 8 V.S.A. § 4062d is added to read:
§ 4062d. Uniform Provider Credentialing
(a) Definitions. As used in this section:
(1) “Credentialing” means a process through which an insurer
makes a determination:
(A) based on criteria established by the insurer; and
(B) concerning whether a provider is eligible to:
(i) provide health care services to an insured; and
(ii) receive reimbursement for the health care services.
(2) “Health care services” means health care‑related services or products rendered or sold by a provider within the scope of the provider’s license or legal authorization, including hospital, medical, surgical, dental, vision, and pharmaceutical services or products.
(3) “Insured” means an individual entitled to reimbursement for
expenses of health care services under a policy issued or administered
by an insurer.
(4) “Insurer” has the same meaning as in subdivision 9402(9) of Title 18.
(5) “Provider” has the same meaning as in subdivision 9402(8) of Title 18.
(b) The department shall prescribe the credentialing application form used by the Council for Affordable Quality Healthcare (CAQH) in electronic or paper format, which must be used by:
(1) a provider who applies for credentialing by an insurer; and
(2) an insurer that performs credentialing activities.
(c) An insurer shall notify a provider concerning a deficiency on a completed credentialing application form submitted by the provider not later than 30 business days after the insurer receives the completed credentialing application form.
(d) An insurer shall notify a provider concerning the status of the provider’s completed credentialing application not later than:
(1) Sixty days after the insurer receives the completed
credentialing application form; and
(2) Every 30 days after the notice is provided under subdivision (1) of this subsection, until the insurer makes a final credentialing determination concerning the provider.
The Vermont General Assembly
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