Washington State

House of Representatives

Office of Program Research

BILL

ANALYSIS

Health Care & Wellness Committee

HB 1552

This analysis was prepared by non-partisan legislative staff for the use of legislative members in their deliberations. This analysis is not a part of the legislation nor does it constitute a statement of legislative intent.

Brief Summary of Bill

Requires a health carrier to approve or deny a credentialing application submitted to the carrier no later than 45 days after receiving a complete application.
Requires health carriers to reimburse a health care provider for covered health care services provided to the carrier's enrollees during the credentialing process if the provider's application is approved and a contractual relationship existed.

Background:

Provider credentialing is the process that insurance carriers use to ensure that a health care provider is qualified to provide care and treatment to their members.

The Office of the Insurance Commissioner (OIC) is required designate a lead organization to develop a uniform electronic process for collecting and transmitting the necessary provider-supplied data to support credentialing, admitting privileges, and other related processes. The OIC selected OneHealthPort as the lead organization, which developed the credentialing database, ProviderSource.

Health care providers are required to submit credentialing applications to ProviderSource and health carriers are required to accept and manage credentialing applications from the database. A health carrier must approve or deny a credentialing application submitted to the carrier no later than 90 days after receiving a complete application from a health care provider.

Beginning June 1, 2020, the average response time for the health carrier to make a determination regarding the approval or denial of a provider's credentialing application may not exceed 60 days. If there is a credentialing delegation arrangement between a facility that employs health care providers and a health carrier, then the single credentialing database is not required to be used and the timelines do not apply.

Summary of Bill:

A health carrier may not require a health care provider to submit credentialing information in any format other than the database selected by the Office of the Insurance Commissioner for purposes of collecting and transmitting credentialing information.

Beginning January 1, 2020, a health carrier must approve or deny a credentialing application submitted to the carrier no later than 45 days after receiving a complete application from a health care provider. An application is complete once it has been attested by the applicant and submitted. Health carriers may not extend the 45 day timeline based upon requests for supplemental information.

The provisions requiring the use of the credentialing database and the approval and denial timelines do not apply to health care entities that utilize credentialing delegation arrangements with carriers.

A health carrier must reimburse a health care provider for covered health care services provided to the carrier's enrollees during the credentialing process beginning when the health care provider submitted a completed application to the carrier if:

the provider's application is approved; and
a contractual relationship existed between the carrier and the health care provider or the entity for whom the health care provider is employed or engaged at the time the health care provider submitted the credentialing application.

The health carrier must reimburse the health care provider at the in-network rate for the applicable health benefit plan that the health care provider would have been paid at the time the services were provided if the health care provider were fully credentialed by the carrier.