Vermont § 9408a - Uniform provider credentialing

§ 9408a. Uniform provider credentialing

• (a) Definitions. As used in this section: (1) “Credentialing” means a process through which an insurer or hospital makes a determination,
  based on criteria established by the insurer or hospital, concerning whether a provider
  is eligible to: (A) provide health care services to an insured or hospital patients; and (B) 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(8) of this title. (5) “Provider” has the same meaning as in subdivision 9402(7) of this title. (b) The Department shall prescribe the credentialing application form used by the Council
  for Affordable Quality Healthcare (CAQH), or a similar, nationally recognized form
  prescribed by the Commissioner, in electronic or paper format, which must be used
  beginning January 1, 2007 by an insurer or a hospital that performs credentialing.
  The Commissioner may grant a hospital an extension to the implementation date for
  up to one year. (c) An insurer or a hospital 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 or hospital receives the completed credentialing application
  form. (d) A hospital shall notify a provider concerning the status of the provider’s completed
  credentialing application not later than: (1) 60 days after the hospital receives the completed credentialing application form;
  and (2) every 30 days after the notice is provided under subdivision (1) of this subsection,
  until the hospital makes a final credentialing determination concerning the provider. (e) [Repealed.] (f) An insurer shall act upon and finish the credentialing process of a completed application
  submitted by a provider within 60 calendar days after receipt of the application.
  An application shall be considered complete once the insurer has received all information
  and documentation necessary to make its credentialing determination as provided in
  subsections (b) and (c) of this section. (Added 2005, No. 191 (Adj. Sess.), § 56; amended 2007, No. 70, § 30; 2007, No. 203 (Adj. Sess.), § 30, eff. June 10, 2008; 2015, No. 152 (Adj. Sess.), § 3; 2023, No. 6, § 227, eff. July 1, 2023.)