An Act To Require Payment by a Carrier for Health Care Services Provided to Enrollees of the Carrier 1
Maine Legislature, Session 127, LD 0124
Committee Amendment CA_A_S47 (Senate)
Amends: 24-A MRSA §4303

COMMITTEE AMENDMENT" A" to S.P. 58, L.D. 124, Bill, "An Act To Require 
Payment by a Carrier for Health Care Services Provided to Enrollees of the Carrier" 
1 
Amend the bill by striking out everything after the enacting clause and before the 
summary and inserting the following: 
'Sec. 1. 24-A MRSA §4303, sub-§2, as amended by PL 2:013, c. 383, §4, is 
further amended to read: 
2. 
Credentialing. The credentialling credentialing of providers by a carrier 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 credentialing. A carrier 
shall consult with appropriately qualified health care professionals in developing its 
credentialling credentialing standards. 
B. All credentialling credentialing 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 credentialing 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 n~lating to the denial 
of credentialling credentialing for not meeting the objective credentialling 
credentialing 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 calTier and a provider 
network if a carrier does not contract with providers individually. 
D. 
A carrier shall make credentialling credentialing decisions, including those 
granting or denying credentials, within 60 days of receipt of a completed 
credentialling credentialing application from a provider. The time period for granting 
COMMITTEE AMENDMENT 
~ 
ROFS 
COMMITTEE AMENDMENT" A" to S.P. 58, L.D. 124 
or denying credentials may be extended upon written notification from the carrier 
within 60 days following submission of a completed application stating that 
information contained in the application requires additional time for verification. All 
credentialling credentialing 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 
oredentialling credentialing 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. 24-A MRSA §4303, sub-§2-A is enacted to read: 
2-A. 
Payment . to provider for services rendered durin!! pendency of 
credentialing. A carrier offering or renewing a health plan in the State shall pay claims 
for services rendered to an enrollee by a provider prior to credentials being granted from 
I 8 
the date a complete application for credentialing is submitted to the carrier as long as 
credentials are granted to that provider by the carrier in accordance with the requirements 
of subsection 2. A provider intending to submit a claim pursuant to this subsection may 
not submit the claim until the provider has been notified by the carrier whether the 
provider has been credentialed and of the effective date of any credentials. If a claim is 
submitted prior to the date credentials are granted, the carrier may process that claim in 
the same manner as a claim submitted by a provider that has not been credentialed. I 
SUMMARY 
This amendment replaces the bill. The amendment requires carriers to pay providers 
for services rendered prior to credentials being granted, retroactive to when a complete 
application for credentialing is submitted, as long as credentials are granted to that 
provider by the carrier. The bill required retroactive payment to a provider for services 
rendered up to 60 days prior to credentials being granted. The amendment clarifies that a 
claim may not be submitted until the provider has been notified of the credentialing 
decision and the effective date of any credentials. 
The amendment makes a spelling change to match the preferred spelling of the 
relevant national accrediting organization. 
FISCAL NOTE REQUIRED 
(See attached) 
COMMITTEE AMENDMENT 
" 
" 
.:-.;;~;, 
;O~\":fr:~. ~: 
'. 
# 
~ 
: 
f, 
'. 't 
~4 
'l<i;; • '",,,. ' '\;'-1 
'-:.:-l~;.-:'~;>;:'/ 
Revised: 04108115 
.?dac:.. 
LD 124 
LR 1150(02) 
An Act To Require Payment by a Carrier for Health Care Services Provided to Enrollees of the 
Carrier 
Fiscal Note for Bill as Amended by Committee Amendment "f{' (3-~"I ') 
Committee: Insurance and Financial Services 
Fiscal Note Required: Yes 
Fiscal Note 
Minor cost increase - Other Special Revenue Funds 
Fiscal Detail and Notes 
Any additional costs to the Department of Professional and Financial Regulation to adopt the changes in this bill are 
expected to be minor and can be absorbed within existing budgeted resources. 
LRl150(02) - Fiscal Note - Page 1 of 1