Maine Legislature, Session 121, LD 0423
Committee Amendment CA_A_H116 (House)

COMMITTEE AMENDMENT "fJ" to H.P. 331, L.D. 423, Bill, 
Act 
To 
Improve 
the 
Process 
of 
Credentialling 
Health 
Providers" 
"An 
Care 
Amend the bill by striking out everything after the enacting 
clause and before the summary and inserting in its place the 
following: 
'Sec. 1. 24-A MRS A §4303, sub-§2, as amended by PL 1997, c. 
163, §1, is further amended to read: 
2. 
Credentiallinq. 
The credentialling of providers by a 
carrier 
e~~eFiB~--a--maBa~eQ--eaFe--p*aB is 
governed 
by 
this 
subsection. 
A. 
The granting of credentials must be based on objective 
standards that are available to providers upon application 
for 
credentialling. 
A 
carrier 
shall 
consult 
with 
appropriately 
qualified 
health 
care 
professionals 
in 
developing its credentialling standards. 
B. 
All credentialling decisions, including those granting, 
denying or withdrawing credentials, must be in writing. 
The 
provider must be provided with all reasons for the denial of 
an 
application for 
credentialling or 
the withdrawal 
of 
credentials. 
A withdrawal of credentials must be treated as 
a provider termination and is subject to the requirements of 
subsection 3-A. 
C. 
A carrier shall 
establish 
and 
maintain 
an 
appeal 
procedure, including the provider's right to a hearing, for 
dealing with provider concerns relating to the denial of 
Page l-LR0750(2) 
COMMITTEE AMENDMENT 
,. 
~. 
COMMITTEE AMENDMENT ,,~. to H.P. 331. L.D. 423 
credentialling for not meeting the objective credentialling 
standards 
of 
the plan 
and 
the contractual 
relationship 
between the carrier and the provider. 
The superintendent 
shall determine whether the process provided by a carrier is 
fair and reasonable. 
This procedure must be specified in 
every contract between a carrier and a provider or between a 
carrier 
and 
a 
provider 
network if a 
carrier 
does 
not 
contract with providers individually. 
D. 
A carrier shall make credentialling decisions. including 
those granting or denying credentials. within 60 days of 
receipt of a 
completed credentialling application from a 
provider. 
The 
time 
period 
for 
granting 
or 
denying 
credentials may be extended upon written notification from 
the 
carrier within 
days 
following 
submission 
of 
a 
completed application stating that information contained in 
the application requires additional time for verification. 
All credentialling decisions must be made within 180 days of 
receipt of a 
completed application. 
For the purposes of 
this 
paragraph. 
an 
application 
is 
completed 
if 
the 
application includes all of the information required by the 
uniform credentialling application used by carriers 
and 
providers 
in 
this 
State. 
such 
attachments 
to 
that 
application as 
required by the carrier at the time of 
application and all corrections required by the carrier. A 
carrier shall review the entire application before returning 
it to the provider for corrections with a comprehensive list 
of all corrections needed at the time the application is 
first returned to the provider. 
A carrier may not require 
that a provider have a home address within the State before 
accepting an application. 
Sec. 2. 
Rulemaking. 
The 
Department 
of 
Professional 
and 
Financial Regulation, Bureau of Insurance may amend Bureau of 
Insurance 
Rule 
Chapter 
850, 
Health 
Plan Accountability, 
to 
conform to the requirements of this Act. 
Notwithstanding the 
Maine Revised Statutes, Title 24-A, section 4309, rules adopted 
pursuant to this section are routine technical rules as defined 
in Title 5, chapter 375, subchapter 2-A.' 
SUMMARY 
This amendment replaces the bill. 
The amendment retains the 
general requirement that carriers make credentialling decisions 
within 
days of rece1v1ng 
a 
completed application from 
a 
provider, but allows a carrier to extend the period for up to 
another 
days 
upon 
written 
notice 
to 
the 
provider 
if 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "~,, to H.P. 33l, L.D. 423 
information 
within 
the 
application 
needs 
verification. 
It 
requires carriers to review the application and return it once 
for all corrections and clarifies that the application is not 
complete until all corrections are made. 
The 
amendment also 
removes the provision making credentialling decisions retroactive 
to the date the carrier received the completed application. 
The 
amendment gives authority to the Department of Professional and 
Financial Regulation, Bureau of Insurance to amend its rules to 
conform to these requirements. 
COMMITTEE AMENDMENT