SECOND REGULAR SESSION

HOUSE BILL NO. 1490

96TH GENERAL ASSEMBLY


 

 

INTRODUCED BY REPRESENTATIVES FREDERICK (Sponsor), KIRKTON, WHITE, CARTER, PACE, SIFTON, SATER, HOUGHTON AND NANCE (Co-sponsors).

5479L.01I                                                                                                                                                  D. ADAM CRUMBLISS, Chief Clerk


 

AN ACT

To amend chapter 376, RSMo, by adding thereto three new sections relating to the credentialing and payment of health care practitioners by health insurers.




Be it enacted by the General Assembly of the state of Missouri, as follows:


            Section A. Chapter 376, RSMo, is amended by adding thereto three new sections, to be known as sections 376.1575, 376.1578, and 376.1580, to read as follows:

            376.1575. As used in sections 376.1575 to 376.1580, the following terms shall mean:

            (1) "Completed application", a practitioner's application to a health carrier that seeks the health carrier's authorization for the practitioner to provide patient care services as a member of the health carrier's network and does not omit any information which is clearly required by the application form or the accompanying instructions;

            (2) "Credentialing", a health carrier's process of assessing and validating the qualifications of a practitioner to provide patient care services and act as a member of the health carrier's provider network;

            (3) "Health carrier", the same meaning as such term is defined in section 376.1350;

            (4) "Practitioner":

            (a) A physician or physician assistant eligible to provide treatment services under chapter 334;

            (b) A pharmacist eligible to provide services under chapter 338;

            (c) A dentist eligible to provide services under chapter 332;

            (d) A chiropractor eligible to provide services under chapter 331;

            (e) An optometrist eligible to provide services under chapter 336;

            (f) A podiatrist eligible to provide services under chapter 330;

            (g) A psychologist or licensed clinical social worker eligible to provide services under chapter 337; or

            (h) An advanced practice nurse eligible to provide services under chapter 335.

            376.1578. 1. (1) Within forty-eight hours after receipt of an electronically filed credentialing application by a health carrier, the carrier shall send an electronic notice of receipt to the practitioner.

            (2) Within five calendar days after receipt of a paper credentialing application by a health carrier, the carrier shall send a notice of receipt to the practitioner.

            2. A health carrier shall assess a health care practitioner's credentialing information and make a decision as to whether to approve or deny the practitioner's credentialing application within sixty calendar days of the date of receipt of the completed application. The sixty-day deadline established in this section shall not apply if the application or subsequent verification of information indicates that the practitioner has:

            (1) A history of behavioral disorders or other impairments affecting the practitioner's ability to practice, including but not limited to substance abuse;

            (2) Licensure disciplinary actions against the practitioner's license to practice imposed by any state or territory or foreign jurisdiction;

            (3) Had the practitioner's hospital admitting or surgical privileges or other organizational credentials or authority to practice revoked, restricted, or suspended based on the practitioner's clinical performance; or

            (4) A judgment or judicial award against the practitioner arising from a medical malpractice liability lawsuit.

            3. The department of insurance, financial institutions and professional registration shall establish a mechanism for reporting alleged violations of this section to the department. Repeated violations of this section by a health carrier shall constitute an unfair trade practice in the business of insurance, as defined in sections 375.394 and 375.396, by limiting the insured's full freedom of choice in the selection of licensed providers as described in paragraph (b) of subdivision (11) of section 375.396.

            376.1580. 1. Within ten business days of receiving a completed application from a practitioner, a health carrier shall permit a practitioner to bill and be paid directly by the insurer for providing treatment services as of the date of receipt of the credentialing application to the enrollees of the health carrier while the credentialing application is under review, subject to the following limitations:

            (1) The health carrier may limit the payment rate to the fee schedule or other reimbursement mechanism applicable to practitioners who are not included in the health carrier's network of contracted providers;

            (2) The health carrier may refuse to allow a practitioner the capacity to bill and be directly paid if the practitioner is not affiliated with an entity that has a current contractual relationship with the health carrier to provide treatment services to the health carrier's enrollees as part of the carrier's provider network;

            (3) The health carrier may refuse to list the practitioner in a directory or other list of providers made available to the health carrier's enrollees as part of the health carrier's provider network;

            (4) The health carrier may refuse to allow the practitioner to be designated as an enrollee's designated primary care or care coordinating practitioner while the credentialing application is pending; and

            (5) Any obligation to allow a practitioner to bill and be directly paid under this section shall cease upon the health carrier's providing notice to the practitioner that the practitioner's credentialing application has been denied, provided that treatment services rendered prior to the date of receipt of the denial shall be eligible to be billed and directly paid.

            2. Nothing in this section shall require a health carrier to pay for treatment services which are excluded from the health carrier's benefit plan.