AB 1187

This bill requires defined network plans to issue provisional approvals to

individual health care providers who submit a completed application, contract, or

letter of intent to become a participating provider in a plan's network and who agree

to the plan's terms for providers of the same type. Defined network plans are health

benefit plans that require or provide incentives for their enrollees to use providers

that are managed, owned, under contract with, or employed by the insurer that offers

the health benefit plan. Defined network plans include such plans as health

maintenance organizations, including, for purposes of this bill, health maintenance

organizations that serve Medical Assistance recipients, and some preferred provider

plans. Current law requires defined network plans to develop a process for selecting

and establishing minimum professional requirements for participating providers,

which must include verifying providers' credentials and the history of any liability

claims made against providers. The bill requires a defined network plan to ensure

that any entity that it contracts with to perform review or verification also complies

with the bill. The bill requires defined network plans to notify providers of the final

approval or denial of participating provider status in writing along with the effective

date of the approval or denial.

A provisional approval under the bill allows the applicant provider to provide

services and obtain reimbursement as if the applicant is a participating provider

under the plan before the applicant attains final approval to be a participating

provider effective on the date the plan receives the provider's application, contract,

or letter of intent. The bill prohibits a plan from recouping any payments it makes

to a provider during the period the provisional approval is effective. If the plan

ultimately denies the provider's application, contract, or letter of intent, the plan

must reimburse the provider for services provided during the period the provisional

approval was effective for at least two weeks following the date that the provider's

application, contract, or letter of intent is denied.