CHAPTER 108
H.P. 331 - L.D. 423
An Act To Improve the Process of Credentialling Health Care Providers
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §4303, sub-§2, as amended by PL 1997, c. 163, §1, is further amended to read:
2. Credentialling. The credentialling of providers by a carrier offering a managed care plan is governed by this subsection.
A. The granting of credentials must be based on objective standards that are available to providers upon application for credentialling. A carrier shall consult with appropriately qualified health care professionals in developing its credentialling standards.
B. All credentialling decisions, including those granting, denying or withdrawing credentials, must be in writing. The provider must be provided with all reasons for the denial of an application for credentialling or the withdrawal of credentials. A withdrawal of credentials must be treated as a provider termination and is subject to the requirements of subsection 3-A.
C. A carrier shall establish and maintain an appeal procedure, including the provider's right to a hearing, for dealing with provider concerns relating to the denial of credentialling for not meeting the objective credentialling standards of the plan and the contractual relationship between the carrier and the provider. The superintendent shall determine whether the process provided by a carrier is fair and reasonable. This procedure must be specified in every contract between a carrier and a provider or between a carrier and a provider network if a carrier does not contract with providers individually.
D. A carrier shall make credentialling decisions, including those granting or denying credentials, within 60 days of receipt of a completed credentialling application from a provider. The time period for granting or denying credentials may be extended upon written notification from the carrier within 60 days following submission of a completed application stating that information contained in the application requires additional time for verification. All credentialling decisions must be made within 180 days of receipt of a completed application. For the purposes of this paragraph, an application is completed if the application includes all of the information required by the uniform credentialling application used by carriers and providers in this State, such attachments to that application as required by the carrier at the time of application and all corrections required by the carrier. A carrier shall review the entire application before returning it to the provider for corrections with a comprehensive list of all corrections needed at the time the application is first returned to the provider. A carrier may not require that a provider have a home address within the State before accepting an application.
Sec. 2. Rulemaking. The Department of Professional and Financial Regulation, Bureau of Insurance may amend Bureau of Insurance Rule Chapter 850, Health Plan Accountability, to conform to the requirements of this Act. Notwithstanding the Maine Revised Statutes, Title 24-A, section 4309, rules adopted pursuant to this section are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
Effective September 13, 2003, unless otherwise indicated.
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