§ 27-19-74. Healthcare provider credentialing.
(a) For applications received on or after January 1, 2018, a healthcare entity or health plan operating in the state shall be required to issue a decision regarding the credentialing of a healthcare provider as soon as practicable, but no later than forty-five (45) calendar days after the date of receipt of a complete credentialing application.
(b) For minor changes to the demographic information of an individual healthcare provider who is already credentialed with a particular healthcare entity or health plan, such healthcare entity or health plan shall complete such change within seven (7) business days of receipt of the healthcare provider’s request. Minor changes to demographic information requested by individual providers shall be submitted in the timeframe, and manner required by the healthcare entity or health plan, and shall include all supporting documentation required by the particular healthcare entity or health plan. For purposes of this section, minor changes to the information profile of a healthcare provider shall include, but not be limited to, changes of address and changes to a healthcare provider’s tax identification number.
(c) Each healthcare entity or health plan shall establish a written standard defining what elements constitute a complete credentialing application and shall distribute this standard with the written version of the credentialing application and make such standard available on the healthcare entity’s or health plan’s website.
(d) Each healthcare entity or health plan shall respond to inquiries by the applicant regarding the status of an application.
(1) Each healthcare entity or health plan shall provide the applicant with automated application status updates, at least once every fifteen (15) calendar days, informing the applicant of any missing application materials until the application is deemed complete;
(2) Each healthcare entity or health plan shall inform the applicant within five (5) business days that the credentialing application is complete; and
(3) If the healthcare entity or health plan denies a credentialing application, the healthcare entity or health plan shall notify the healthcare provider in writing and shall provide the healthcare provider with any and all reasons for denying the credentialing application.
(e) The effective date for billing privileges for healthcare providers under a particular healthcare entity or health plan shall be the next business day following the date of approval of the credentialing application.
(f) For applications received from resident graduates on or after January 1, 2018, a healthcare entity or health plan shall offer a transitional or conditional approval process such that a resident graduate who has submitted an otherwise complete application and met all other criteria, may be conditionally approved, effective upon successful graduation from the training program.
(g) For the purposes of this section, the following definitions apply:
(1) “Complete credentialing application” means all the requested material has been submitted.
(2) “Date of receipt” means the date the healthcare entity or health plan receives the completed credentialing application whether via electronic submission or as a paper application.
(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or medical or dental service corporation or plan or health maintenance organization, or a contractor as defined in § 23-17.13-2 [repealed] that operates a health plan.
(4) “Healthcare provider” means a healthcare professional.
(5) “Health plan” means a plan operated by a healthcare entity that provides for the delivery of healthcare services to persons enrolled in those plans through:
(i) Arrangements with selected providers to furnish healthcare services; and
(ii) Financial incentives for persons enrolled in the plan to use the participating providers and procedures provided for by the health plan.
History of Section.P.L. 2017, ch. 185, § 2; P.L. 2017, ch. 254, § 2.
Structure Rhode Island General Laws
Chapter 27-19 - Nonprofit Hospital Service Corporations
Section 27-19-1. - Definitions.
Section 27-19-2. - Organization as charitable corporation — Insurance laws inapplicable.
Section 27-19-2.1. - Investments and holdings in certain corporations authorized.
Section 27-19-4. - Certificate of public convenience and advantage.
Section 27-19-5. - Contracts with subscribers, hospitals, and other eligible entities.
Section 27-19-5.1. - Cancellation of coverage by employers.
Section 27-19-5.2. - Patient responsibility — Administrative requirements.
Section 27-19-5.3. - Additional powers.
Section 27-19-6. - Rates charged subscribers — Reserves. [Effective until January 1, 2023.]
Section 27-19-7. - Rates charged by hospitals.
Section 27-19-7.1. - Uniform explanation of benefits and coverage.
Section 27-19-7.2. - Filing of policy forms.
Section 27-19-8. - Annual and quarterly statements.
Section 27-19-9. - Examination of affairs of corporations.
Section 27-19-10. - Commission plans for solicitors or insurance producers.
Section 27-19-11. - Investment standards.
Section 27-19-12. - Corporations deemed public charitable institutions.
Section 27-19-13. - Services rendered in certain institutions.
Section 27-19-17. - Additional benefits.
Section 27-19-18. - Coverage for adoptive children.
Section 27-19-19. - Changing coverage.
Section 27-19-20. - Mammograms and pap smears — Coverage mandated.
Section 27-19-21. - Mammograms — Quality assurance standards.
Section 27-19-22. - Pap smears — Quality assurance standards.
Section 27-19-23. - Coverage for infertility.
Section 27-19-23.1. - Insurance coverage for post-partum hospital stays.
Section 27-19-24. - Nonprofit hospital service corporations assessment.
Section 27-19-25. - Discontinuance of coverage — Chronic disabilities.
Section 27-19-26. - Drug coverage.
Section 27-19-26.1. - Medication synchronization.
Section 27-19-28. - Rehabilitation, liquidation, or conservation.
Section 27-19-29. - Holding company systems.
Section 27-19-29.1. - No derogation of attorney general.
Section 27-19-30. - Regulations.
Section 27-19-30.1. - Health insurance rates.
Section 27-19-32.1. - Repealed.
Section 27-19-32.2. - Repealed.
Section 27-19-32.3. - Repealed.
Section 27-19-34. - Mastectomy treatment.
Section 27-19-34.1. - Insurance coverage for mastectomy hospital stays.
Section 27-19-35. - Diabetes treatment.
Section 27-19-36. - Primary and preventive obstetric and gynecological care.
Section 27-19-36.1. - Hysterectomy or myomectomy treatment.
Section 27-19-37. - Whistleblowers protection.
Section 27-19-38. - Penalties and remedies.
Section 27-19-39. - Additional relief and damages — Reinstatement.
Section 27-19-40. - Third-party reimbursement for services of certain healthcare workers.
Section 27-19-40.1. - Third party reimbursement for services of registered nurse first assistants.
Section 27-19-41. - Human leukocyte antigen testing.
Section 27-19-42. - Drug coverage.
Section 27-19-43. - Restricted annual rate payments prohibited.
Section 27-19-44. - Genetic testing.
Section 27-19-44.1. - Genetic information.
Section 27-19-46. - Magnetic resonance imaging — Quality assurance standards.
Section 27-19-47. - Acupuncture services.
Section 27-19-48. - F.D.A. approved prescription contraceptive drugs and devices.
Section 27-19-50. - Eligibility for children’s benefits.
Section 27-19-51. - Hearing aids.
Section 27-19-52. - Prompt processing of claims.
Section 27-19-53. - Mandatory coverage for certain lyme disease treatments.
Section 27-19-54. - Dental insurance assignment of benefits.
Section 27-19-55. - Coverage for early intervention services.
Section 27-19-56. - Post-payment audits.
Section 27-19-57. - Tobacco cessation programs.
Section 27-19-58. - Reimbursement for orthotics and prosthetic services.
Section 27-19-59. - Mandatory coverage for scalp hair prosthesis.
Section 27-19-60. - Licensed ambulance service.
Section 27-19-61. - Enteral nutrition products.
Section 27-19-62. - Prohibition on rescission of coverage.
Section 27-19-63. - Prohibition on annual and lifetime limits.
Section 27-19-64. - Coverage for individuals participating in approved clinical trials.
Section 27-19-65. - Medical loss ratio reporting and rebates.
Section 27-19-66. - Emergency services.
Section 27-19-67. - Internal and external appeal of adverse benefit determinations.
Section 27-19-68. - Prohibition on preexisting condition exclusions.
Section 27-19-69. - Primary care provider designation requirement.
Section 27-19-70. - Discretionary clauses.
Section 27-19-71. - Orally administered anticancer medication — Cost-sharing requirement.
Section 27-19-72. - Consumer notification.
Section 27-19-73. - Opioid antagonists.
Section 27-19-74. - Healthcare provider credentialing.
Section 27-19-75. - Unfair discrimination prohibited.
Section 27-19-76. - Health insurance contracts — Full year coverage for contraception.
Section 27-19-77. - Prohibition on discrimination in organ transplants.
Section 27-19-78. - Health insurance contracts — Copayments exemption for COVID-19 vaccinations.
Section 27-19-79. - Perinatal doulas.
Section 27-19-80. - Gender rating. [Effective January 1, 2023.]