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  • Summary date: Mar 28 2019 - View Summary

    Recodifies GS 58-3-230, Uniform provider credentialing, as GS 58-50-271. Makes conforming changes to GS 58-3-245. Amends GS 58-50-271, as enacted. Modifies the existing credentialing provisions to make them applicable to licensed health care providers entering into new insurer contracts, instead of limiting the credentialing to licensed health care practitioners. Adds new provisions to require insurers providing a health benefit plan and credentialing providers for its networks to establish reasonable protocols and procedures for reimbursing health care provider applicants for covered health care services provided to insureds during the period in which the applicant's competed provider credentialing application is pending, including services provided prior to the issuance of a temporary credential. Limits application of the protocols and procedures to health care provider's credentialing applications approved. Details minimum requirements for the protocols and procedures.

    Enacts provisions regarding credentialing for group practices with existing insurer contracts. Requires an insurer that has an existing contract with a group health care provider practice to participate in a health benefit plan network that credentials providers for its networks. Additionally requires the insurer to maintain a process to assess and verify the qualifications of a new health care provider that joins the group practice within 60 days of receipt of a completed provider credentialing application form approved by the Commissioner of Insurance. Requires the insurer to provide to the group practice a list of all information and supporting documentation required for credentialing a new health care provider that joins the practice. Details requirements, concerning notifications and claims pending application, that apply to the credentialing process for a new health care provider that joins a group practice that has an existing contract with an insurer to participate in a health benefit plan. 

    Clarifies that nothing in the statute requires reimbursement of health care provider-rendered services that are not benefits or services covered by the insurer's health benefit plan. Makes conforming changes.

    Retitles Article 41, Chapter 90, as Health Care Services Billing (was Pathology Services Billing).

    Enacts GS 90-702 limiting reimbursement for a health care provider's provision of services pending credentialing application approval that is later denied and the provider does not otherwise contract as part of the health benefit plan's provider network to an amount which would have been required to be paid by the patient had the provider been in-network with the health benefit plan at the time the services were rendered.

    Applies to provider credentialing applications received on or after October 1, 2019.