Provisional approval as a participating provider in a defined network health plan

What it would have done

Summary by the Legislative Reference Bureau, the Legislature's nonpartisan drafting office. It's their wording, not ours.

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.

Who's behind it

Tip McGuire, a Democrat, is its author⁠.