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      RS 22:1009     


§1009. Health care provider credentialing

            A. As used in this Section, the following words and phrases have the following meanings ascribed for each, unless the context clearly indicates otherwise:

            (1) "Applicant" means a health care provider seeking to be approved or credentialed by an issuer to provide health care services to the issuer's enrollees or insureds.

            (2) "Commissioner" means the commissioner of insurance.

            (3) "Credentialing" or "recredentialing" means the process of assessing and validating the qualifications of health care providers applying to be approved by a health insurance issuer to provide health care services to the health insurance issuer's enrollees or insureds.

            (4) "Enrollee or insured" means an individual who is enrolled or insured by a health insurance issuer for health insurance coverage.

            (5) "Health care provider" or "provider" means a physician licensed to practice medicine by the Louisiana State Board of Medical Examiners, a dentist licensed to practice dentistry by the Louisiana State Board of Dentistry, or other individual health care practitioner licensed, certified, or registered to perform specified health care services consistent with state law.

            (6) "Health care services" or "services" means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.

            (7) "Health insurance issuer" or "issuer" means any insurer who offers health insurance coverage through a plan, policy, or certificate of insurance subject to state law that regulates the business of insurance. A "health insurance issuer" or "issuer" shall also include a health maintenance organization, as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title, a dental benefit plan, including an entity defined as a dental service contractor in Subpart G of this Part, and shall include the Office of Group Benefits programs.

            (8) "Standardized information" means customary universal data concerning an applicant's identity, education, and professional experience relative to an issuer's credentialing process, including but not limited to name, address, telephone number, date of birth, social security number, educational background, state licensing board number, residency program, internship, specialty, subspecialty, fellowship, or certification by a regional or national health care or medical specialty college, association or society, prior and current place of employment, an adverse medical review panel opinion, a pending professional liability lawsuit, final disposition of a professional liability settlement or judgment, and information mandated by health insurance issuer accrediting organizations.

            (9) "Verification" or "verification supporting statement" means documentation confirming the information submitted by an applicant for a credentialing application from a specifically named entity or a regional, national, or general data depository providing primary source verification, including but not limited to a college, university, medical school, teaching hospital, health care facility or institution, state licensing board, federal agency or department, professional liability insurer, or the National Practitioner Data Bank.

            B.(1) Any health insurance issuer that requires a health care provider to be credentialed, recredentialed, or approved by the issuer prior to rendering health care services to an enrollee or insured shall complete a credentialing process within ninety days from the date on which the issuer has received all the information needed for credentialing, including the health care provider's correctly completed application and attestations and all verifications or verification supporting statements required by the issuer to comply with accreditation requirements and generally accepted industry practices and provisions to obtain reasonable applicant-specific information relative to the particular or precise services proposed to be rendered by the applicant.

            (2)(a) Within thirty days of the date of receipt of an application, a health insurance issuer shall inform the applicant of all defects and reasons known at the time by the issuer in the event a submitted application is deemed to be not correctly completed.

            (b) A health insurance issuer shall inform the applicant in the event that any needed verification or a verification supporting statement has not been received within sixty days of the date of the issuer's request.

            (3) In order to establish uniformity in the submission of an applicant's standardized information to each issuer for which he may seek to provide health care services, until submission of an applicant's standardized information in a hard-copy, paper format is superseded by a provider's required submission and a health insurance issuer's required acceptance by electronic submission, an applicant shall utilize and a health insurance issuer shall accept either of the following at the sole discretion of the health insurance issuer:

            (a) The current version of the Louisiana Standardized Credentialing Application Form, or its successor; or

            (b) The current format used by the Council for Affordable Quality Healthcare (CAQH), or its successor.

            (4) The commissioner, at his discretion, is hereby authorized and may, for good cause shown, by rule or regulation promulgated pursuant to the provisions of the Administrative Procedure Act, R.S. 49:950 et seq., exempt a health insurance issuer from the requirements of the provisions of Paragraph (3) of this Subsection for any period of time.

            (5) A provider who has been credentialed by a health insurance issuer for any location in the state of Louisiana and is current on all credentialing at such location or locations, shall be considered credentialed for all other locations at which that provider may legally practice medicine or dentistry in the state of Louisiana, provided that each of the following conditions are met:

            (a) Not less than thirty days prior to the time at which the provider begins practicing at any additional location, another provider who is current on all credentialing with that health insurance issuer legally practiced there.

            (b) The provider gives the health insurance issuer written notice of any additional location of practice beyond his primary practice location and any additional practice location originally noted on the provider's initial credentialing application form. The health insurance issuer may require that such notice include such additional information as may be reasonably necessary in order to process claims filed by the provider from the additional location. The credentialing of the provider for any additional location shall be effective immediately upon the receipt by the health insurance issuer of such written notice from the provider.

            (6) Pursuant to Paragraph (5) of this Subsection, there shall be no other requirements placed upon the provider in order to be credentialed by a health insurance issuer for any additional location.

            C. Nothing in this Section shall be construed to require health insurance issuer credentialing or approval in determining inclusion or participation in an issuer's health insurance plan or policy of health insurance coverage for reimbursement of the rendering of treatment to an enrollee or insured by a religious nonmedical practitioner who furnishes only religious nonmedical treatment or religious nonmedical nursing care.

            D. The provisions of this Section shall apply to a preferred provider organization as defined in R.S. 40:2202(5) which engages in credentialing or recredentialing of a provider applicant for approval to provide health care services in its network of providers.

            E. The commissioner shall, as a courtesy to health insurance issuers and health care providers, maintain on the Department of Insurance's website both of the following:

            (1) The current version of the Louisiana Standardized Credentialing Application Form or its successor.

            (2) An electronic link to the current format used by the Council for Affordable Quality Healthcare (CAQH) or its successor.

            Acts 2004, No. 671, §1, eff. Nov. 1, 2004; Acts 2005, No. 374, §1; Redesignated from R.S. 22:11.1 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 919, §1, eff. Jan. 1, 2011; Acts 2015, No. 63, §1, eff. June 5, 2015.

NOTE: Former R.S. 22:1009 redesignated as R.S. 22:707 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.

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