Iowa Administrative Code › Agency 191 - Insurance Division › Managed Health Care › Chapter 70 - Utilization Review › Rule 191-70.10 - Credentialing-retrospective Payment

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Purpose.
This rule implements Iowa Code section
				514F.6,
				which provides for the retrospective payment of clean claims for covered
				services provided by a physician, advanced registered nurse practitioner or
				physician assistant during the credentialing period, once the physician,
				advanced registered nurse practitioner or physician assistant is
				credentialed.
(2)
Definitions.
For purposes of this rule, the definitions found
				in Iowa Code section
				514F.6
				shall apply. In addition, the following definitions shall apply:
"Application date"
means the date on which
				  the health insurer or other entity responsible for the credentialing of health
				  care professionals on behalf of the health insurer receives the health care
				  professional's completed application for credentialing.
"Clean claim"
means clean claim as defined
				  in Iowa Code section
				  507B.4A(2)
"b."
"Health care professional"
means a
				  physician, advanced registered nurse practitioner or physician
				  assistant.
"Health insurer"
means the same as a
				  carrier, as defined in Iowa Code section
				  513B.2(4),
				  that provides health insurance coverage, as defined in Iowa Code section
				  513B.2(12).
(3)
Retrospective payment of clean
				claims.
A health insurer shall make retrospective payment for all
				clean claims submitted by a health care professional after the credentialing
				period for covered services provided by the health care professional during the
				credentialing period subject to all of the following:
a. The credentialing period shall begin on
				the application date and end on the date the health insurer or other entity
				responsible for credentialing health care professionals on behalf of the health
				insurer makes a final determination approving the health care professional's
				application to be credentialed.
b.
				The health insurer or other entity responsible for credentialing health care
				professionals on behalf of the health insurer shall notify an applicant of its
				determination regarding a properly completed application for credentialing
				within 90 days of receipt of an application containing all information required
				by the health insurer's credentialing form.
c. The health care professional shall not
				submit any claims to the health insurer during the credentialing
				period.
d. A health insurer shall
				not be required to pay any claims submitted by a health care professional
				during the credentialing period.
e.
				The health insurer's time period for timely submission of claims shall not
				start until the credentialing period has ended. The health insurer's rules
				pertaining to timely submission shall not be used to deny payment of any clean
				claims for medical services provided by a health care professional during the
				credentialing period, so long as the health care professional submits all such
				claims within the time period required by the health insurer's rules beginning
				on the date the health care professional is credentialed.
f. After the health care professional has
				been credentialed, the health care professional shall submit all claims to the
				health insurer for covered services provided by the health care professional
				during the credentialing period.
g.
				After the health care professional has been credentialed, a health insurer
				shall pay all clean claims submitted by the health care professional for
				covered services provided by the health care professional during the
				credentialing period within the time periods specified in
				191-15.32 (507B).