Health care coverage: health care provider credentials., the official text

An act to add Sections 1374.198 and 1380.2 to the Health and Safety Code, and to add Sections 10110.9 and 10144.565 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL'S DIGEST

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act’s requirements a crime. Existing law provides for the regulation of disability and health insurers by the Department of Insurance.
This bill would require every full service health care service plan or health insurer, or its delegate, to subscribe to and use the Council for Affordable Quality Healthcare credentialing form on and after January 1, 2028, except as specified.
Existing law requires a health care service plan or disability insurer that provides coverage for mental health and substance use disorders and that credentials health care providers of those services for its networks to assess and verify the qualifications of a health care provider within 60 days after receiving a completed provider credentialing application.
This bill would, except as provided above and within one year of the bill’s operative date, require every health care service plan or health insurer, or its delegate, that credentials health care providers for its networks to make a determination regarding the credentials of a provider within 90 days after receiving a completed provider credentialing application. The bill would require every health care service plan or health insurer to activate the provider upon successful approval and notify the applicant of the activation, as specified. If the health care service plan or health insurer, or its delegate, does not meet the 90-day requirement, the bill would require the applicant’s credentials to be provisionally approved for 120 days unless specified circumstances apply, including that the applicant is subject to discipline by the licensing entity for that applicant. The bill would exclude Medi-Cal managed care plans from these provisions.
Because a willful violation of these provisions by a health care service plan would be a crime, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.

The people of the State of California do enact as follows:

SECTION 1.
Section 1374.198 is added to the Health and Safety Code, immediately following Section 1374.197, to read:
1374.198.
(a) Except as provided in Section 1374.197, within one year of the operative date of this section, a health care service plan or its delegate that credentials health care providers for its networks shall make a determination regarding the credentials of a health care provider within 90 days after receiving a completed provider credentialing application, including all required third-party verifications. Upon receipt of the application by the credentialing department, the health care service plan or its delegate shall notify the applicant within 10 business days to verify receipt and inform the applicant whether the application is complete. The health care service plan shall activate the provider upon successful approval and notify the applicant of the activation within 10 days of approval if the approval occurs prior to the end of the 90-day timeline. The 90-day timeline shall apply only to the credentialing process and does not include contracting completion. If the health care service plan or its delegate does not meet the 90-day requirement, the applicant’s credentials shall be provisionally approved for 120 days unless any of the following apply:
(1) The applicant is subject to discipline by the licensing entity for that applicant.
(2) The applicant has one or more adverse action reports or one or more reports of malpractice payments filed with the National Practitioner Data Bank.
(3) The applicant has not been credentialed by the health care service plan in the past five years.
(b) This section does not apply to contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of Welfare and Institutions Code.

SEC. 2.
Section 1380.2 is added to the Health and Safety Code, to read:
1380.2.
(a) (1) Notwithstanding any other law, except as provided in Section 1374.197, on and after January 1, 2028, a full service health care service plan or its delegate shall subscribe to and use the most recent version of the Council for Affordable Quality Healthcare (CAQH) credentialing form, and shall comply with the CAQH credentialing processes.
(2) A full service health care service plan or its delegate shall only request additional information from a provider to clarify and confirm information that is provided on the CAQH credentialing form, including verification of information not specifically disclosed on the provider’s application. The provider shall respond to the request within 10 business days. A health care service plan or its delegate shall minimize the number of requests for additional information from providers. A provider shall submit their credentialing form and maintain their credentialing information in the CAQH database in a manner consistent with CAQH standards.
(b) This section does not apply to contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.

SEC. 3.
Section 10110.9 is added to the Insurance Code, to read:
10110.9.
(a) Notwithstanding any other law, except as provided in Section 10144.56, on and after January 1, 2028, a health insurer or its delegate shall subscribe to and use the most recent version of the Council for Affordable Quality Healthcare (CAQH) credentialing form, and shall comply with the CAQH credentialing processes.
(b) A health insurer or its delegate shall only request additional information from a provider to clarify and confirm information that is provided on the CAQH credentialing form, including verification of information not specifically disclosed on the provider’s application. The provider shall respond to the request within 10 business days. A health insurer or its delegate shall minimize the number of requests for additional information from providers. A provider shall submit their credentialing form and maintain their credentialing information in the CAQH database in a manner consistent with CAQH standards.

SEC. 4.
Section 10144.565 is added to the Insurance Code, immediately following Section 10144.56, to read:
10144.565.
Except as provided in Section 10144.56, within one year of the operative date of this section, a health insurer or its delegate that credentials health care providers for its networks shall make a determination regarding the credentials of a health care provider within 90 days after receiving a completed provider credentialing application, including all required third-party verifications. Upon receipt of the application by the credentialing department, the health insurer or its delegate shall notify the applicant within 10 business days to verify receipt and inform the applicant whether the application is complete. The health insurer shall activate the provider upon successful approval and notify the applicant of the activation within 10 days of approval if the approval occurs prior to the end of the 90-day timeline. The 90-day timeline shall apply only to the credentialing process and does not include contracting completion. If the health insurer or its delegate does not meet the 90-day requirement, the applicant’s credentials shall be provisionally approved for 120 days unless any of the following apply:
(a) The applicant is subject to discipline by the licensing entity for that applicant.
(b) The applicant has one or more adverse action reports or one or more reports of malpractice payments filed with the National Practitioner Data Bank.
(c) The applicant has not been credentialed by the health insurer in the past five years.

SEC. 5.
No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.