Indiana § 27-13-43-2 - Credentialing; application; notification; provisional credential; retroactive reimbursement; termination

§ 27-13-43-2. Credentialing; application; notification; provisional credential; retroactive reimbursement; termination

Sec. 2. (a) As used in this section, "clean credentialing application" means an application for network participation that:

(1) is submitted by a provider under this section;

(2) does not contain an error; and

(3) may be processed by the health maintenance organization without returning the application to the provider for a revision or clarification.

(b) As used in this section, "credentialing" means a process by which a health maintenance organization makes a determination that:

(1) is based on criteria established by the health maintenance organization; and

(2) concerns whether a provider is eligible to:

(A) provide health services to an individual eligible for coverage; and

(B) receive reimbursement for the health services;

under an agreement that is entered into between the provider and the health maintenance organization.

(c) As used in this section, "unclean credentialing application" means an application for network participation that:

(1) is submitted by a provider under this section;

(2) contains at least one (1) error; and

(3) must be returned to the provider to correct the error.

(d) The department shall prescribe the credentialing application form used by the Council for Affordable Quality Healthcare (CAQH) in electronic or paper format. The form must be used by:

(1) a provider who applies for credentialing by a health maintenance organization; and

(2) a health maintenance organization that performs credentialing activities.

(e) A health maintenance organization shall notify a provider concerning a deficiency on a completed unclean credentialing application form submitted by the provider not later than five (5) business days after the entity receives the completed unclean credentialing application form. A notice described in this subsection must:

(1) provide a description of the deficiency; and

(2) state the reason why the application was determined to be an unclean credentialing application.

(f) A provider shall respond to the notification required under subsection (e) not later than five (5) business days after receipt of the notice.

(g) A health maintenance organization shall notify a provider concerning the status of the provider's completed clean credentialing application when:

(1) the provider is provisionally credentialed; and

(2) the health maintenance organization makes a final credentialing determination concerning the provider.

(h) If the health maintenance organization fails to issue a credentialing determination within fifteen (15) business days after receiving a completed clean credentialing application form from a provider, the health maintenance organization shall provisionally credential the provider in accordance with the standards and guidelines governing provisional credentialing from the National Committee for Quality Assurance or its successor organization. The provisional credentialing license is valid until a determination is made on the credentialing application of the provider.

(i) Once a health maintenance organization fully credentials a provider that holds provisional credentialing and a network provider agreement has been executed, then reimbursement payments under the contract shall be paid retroactive to the date the provider was provisionally credentialed. The health maintenance organization shall reimburse the provider at the rates determined by the contract between the provider and the health maintenance organization.

(j) If a health maintenance organization does not fully credential a provider that is provisionally credentialed under subsection (h), the provisional credentialing is terminated on the date the health maintenance organization notifies the provider of the adverse credentialing determination. The health maintenance organization is not required to reimburse for services rendered while the provider was provisionally credentialed.

As added by P.L.26-2005, SEC.4. Amended by P.L.1-2006, SEC.489; P.L.190-2023, SEC.36; P.L.17-2024, SEC.22; P.L.158-2024, SEC.24.