2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 11. Accident and Sickness Insurance─reimbursement Agreements › 27-8-11-7-b. Provider Credentialing

Note: This version of section effective 1-1-2024. See also preceding version of this section, effective until 1-1-2024.
Sec. 7. (a) This section applies to an insurer that issues or administers a policy that provides coverage for basic health care services (as defined in IC 27-13-1-4).
(b) As used in this section, "clean credentialing application" means an application for network participation that:
(1) is submitted by a provider under this section;
(2) does not contain an error; and
(3) may be processed by the insurer without returning the application to the provider for a revision or clarification.
(c) As used in this section, "credentialing" means a process by which an insurer makes a determination that:
(1) is based on criteria established by the insurer; and
(2) concerns whether a provider is eligible to:
(A) provide health services to an individual eligible for coverage; and
(B) receive reimbursement for the health services;
under an agreement that is entered into between the provider and the insurer.
(d) As used in this section, "unclean credentialing application" means an application for network participation that:
(1) is submitted by a provider under this section;
(2) contains at least one (1) error; and
(3) must be returned to the provider to correct the error.
(e) The department of insurance shall prescribe the credentialing application form used by the Council for Affordable Quality Healthcare (CAQH) in electronic or paper format, which must be used by:
(1) a provider who applies for credentialing by an insurer; and
(2) an insurer that performs credentialing activities.
(f) An insurer shall notify a provider concerning a deficiency on a completed unclean credentialing application form submitted by the provider not later than five (5) business days after the entity receives the completed unclean credentialing application form. A notice described in this subsection must:
(1) provide a description of the deficiency; and
(2) state the reason why the application was determined to be an unclean credentialing application.
(g) A provider shall respond to the notification required under subsection (f) not later than five (5) business days after receipt of the notice.
(h) An insurer shall notify a provider concerning the status of the provider's completed clean credentialing application when:
(1) the provider is provisionally credentialed; and
(2) the insurer makes a final credentialing determination concerning the provider.
(i) If the insurer fails to issue a credentialing determination within fifteen (15) days after receiving a completed clean credentialing application form from a provider, the insurer shall provisionally credential the provider in accordance with the standards and guidelines governing provisional credentialing from the National Committee for Quality Assurance or its successor organization. The provisional credentialing license is valid until a determination is made on the credentialing application of the provider.
(j) Once an insurer fully credentials a provider that holds provisional credentialing and a network provider agreement has been executed, then reimbursement payments under the contract shall be paid retroactive to the date the provider was provisionally credentialed. The insurer shall reimburse the provider at the rates determined by the contract between the provider and the insurer.
(k) If an insurer does not fully credential a provider that is provisionally credentialed under subsection (i), the provisional credentialing is terminated on the date the insurer notifies the provider of the adverse credentialing determination. The insurer is not required to reimburse for services rendered while the provider was provisionally credentialed.
As added by P.L.26-2005, SEC.2. Amended by P.L.195-2018, SEC.18; P.L.190-2023, SEC.30.