An Act To Improve the Process of Credentialling Health Care Providers
Maine Legislature, Session 121, LD 0423
Committee: Insurance and Financial Services
Sponsors: MARRACHE, GAGNON, FINCH, GLYNN, PERRY, SMITH
Amends: 24-A MRSA §4303

Legislative Document 
No. 423 
H.P.331 
House of Representatives, February 4,2003 
An Act To Improve the Process of Credentialling Health Care 
Providers 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
Presented by Representative MARRACHE of Waterville. 
Cosponsored by Senator GAGNON of Kennebec and 
/J1~1h.7lbc~ 
Mil..LICENT M. MacFARLAND 
Clerk 
Representatives: FINCH of Fairfield, GLYNN of South Portland, McLAUGHLIN of Cape 
Elizabeth, O'NEil.. of Saco, PERRY of Calais, SMITH of Van Buren. 
Printed on recycled paper 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1. 24-A MRSA §4303, sub-§2, as amended by PL 1997, c. 
163, §1, is further amended to read: 
2. 
Credentialling. 
The credentialling 
carrier 
e~~e~~a~--a--ffiaBa~eQ--ea~e--~~aB is 
subsection. 
of providers 
governed 
by 
by a 
this 
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 
ln 
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 3-11.. 
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 
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, denying or withdrawing credentials, within 
days of receiving a completed credentialling application 
from a provider. 
For the purposes of this paragraph, 
an 
application is completed if the application includes all of 
the 
information 
reguired 
by 
the 
uniform 
credentialling 
application used by carriers and providers in this State, 
and such attachments to that application as reguired by the 
carrier at the 
time 
of 
application. 
A carrier 
may 
not 
reguire that a provider have an address within the State 
before accepting an application. 
A carrier must 
accept 
primary source verification from the Federation of State 
Medical Boards or its successor organization. 
Page l-LR0750(1) 
E. 
If 
the 
credentialling 
application is 
completed 
as 
described in paragraph D and the carrier's decision to grant 
credentials to a provider is made later than 60 days after 
receipt of a completed application, the carrier's approval 
of that provider's credentialling must be retroactive to the 
date 
the 
carrier 
received 
the 
provider's 
completed 
application. 
SUMMARY 
This bill sets a time line for provider credentialling by 
health 
insurance 
carriers. 
It 
requires 
carriers 
to 
make 
credentialling decisions within 60 days of receiving a completed 
application from a provider.