{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.10_1.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.10_1.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.10_1.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.10_1.html"}],"law_id":66411,"edition_id":1,"section_id":66411,"structure_id":12994,"section_number":"38.2-3407.10:1","catch_line":"Processing of new provider applications and reimbursement for services rendered during pendency of a participating provider’s credentialing application","history":"2018, c. 703; 2019, c. 689; 2020, c. 840; 2022, cc. 471, 472; 2023, cc. 376, 377.","full_text":"A\n\nAs used in this section:\n\t\t\t“Carrier” means an entity subject to the insurance laws and regulations of the Commonwealth and subject to the jurisdiction of the Commission that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services or mental health services, including an insurer licensed to sell accident and sickness insurance, a health maintenance organization, a health services plan, or any other entity providing a plan of health insurance, health benefits, health care services, or mental health services.\n\t\t\t“Covered person” means a policyholder, subscriber, enrollee, participant, or other individual covered by a health benefit plan.\n\t\t\t“Health benefit plan” means a policy, contract, certificate, or agreement offered by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.\n\t\t\t“Mental health professional” has the meaning ascribed thereto in § 54.1-2400.1.\n\t\t\t“Mental health services” means benefits with respect to items or services provided by mental health professionals for mental health conditions as defined under the terms of a health benefit plan.\n\t\t\t“Network” means a group of participating providers who provide health care services under the carrier’s health benefit plan that requires or creates incentives for a covered person to use the participating providers.\n\t\t\t“New provider applicant” means a physician, mental health professional, or other provider who has submitted a completed credentialing application to a carrier.\n\t\t\t“Other provider” means a person, corporation, facility, or institution licensed by the Commonwealth under Title 32.1 or 54.1 to provide health care or professional health-related services on a fee basis.\n\t\t\t“Participating mental health professional” means a mental health professional who is managed, under contract with, or employed by a carrier and who has agreed to provide health care services to covered persons with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier.\n\t\t\t“Participating other provider” means an other provider who is managed, under contract with, or employed by a carrier and who has agreed to provide such health care or professional services to covered persons with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier.\n\t\t\t“Participating physician” means a physician who is managed, under contract with, or employed by a carrier and who has agreed to provide health care services or mental health services to covered persons with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier.\n\t\t\t“Participating provider” means a participating physician, participating mental health professional, or participating other provider.\n\t\t\t“Physician” means a doctor of medicine or osteopathic medicine holding an active license from the Board of Medicine.B\n\nA carrier that credentials the physicians, mental health professionals, or other providers in its network shall establish reasonable protocols and procedures for processing new provider credentialing applications and reimbursing new provider applicants for health care services or mental health services provided to covered persons during the period in which an approved applicant’s completed credentialing application was pending. At a minimum, the protocols and procedures shall require the following:1\n\nIf the carrier accepts applications through an online credentialing system, the carrier shall notify a new provider applicant through the online credentialing system that the provider has submitted and attested to the application as notice by the carrier that the application is received. If the carrier does not accept applications through an online credentialing system, the carrier shall within 10 days of receiving an application provide notification to the new provider applicant either by mail or electronic mail, as selected by the applicant, that the application was received;2\n\nBeginning January 1, 2024, a new provider applicant’s application is deemed complete within 30 days of the carrier receiving the application, unless the carrier has provided notice that the application is not complete. Notice shall be provided by electronic mail unless the provider applicant has selected notification by mail;3\n\nThe carrier shall approve or deny new provider applicant credentialing applications within 60 days of receiving a completed application;4\n\nClaims submitted according to carrier claims submittal policies for services rendered during the period of a pending application shall be adjudicated and paid no later than 40 days after the new provider applicant is credentialed and contracted;5\n\nThe protocols and procedures shall apply only if a contractual relationship exists between the carrier and the new provider applicant or entity for whom the new provider applicant is employed or engaged; and6\n\nAny reimbursement shall be paid at the in-network rate that the new provider applicant would have received had he been, at the time the covered health care services were provided, a credentialed participating provider in the network for the applicable health benefit plan.C\n\nNothing in this section shall require reimbursement of the new provider applicant-rendered services that are not benefits or services covered by the carrier’s health benefit plan.D\n\nNothing in this section requires a carrier to pay reimbursement at the contracted in-network rate for any covered health care services or mental health services provided by the new provider applicant if the new provider applicant’s credentialing application is not approved or the carrier is otherwise not willing to contract with the new provider applicant.E\n\nPayments made or retroactive denials of payments made under this section shall be governed by § 38.2-3407.15.F\n\nIf a payment is made by the carrier to a new provider applicant or any entity that employs or engages such new provider applicant under this section for a covered service, the patient shall only be responsible for any coinsurance, copayments, or deductibles permitted under the insurance contract with the carrier or participating provider agreement with the physician, mental health professional, or other provider. If the new provider applicant is not credentialed by the carrier, the new provider applicant or any entity that employs or engages such physician, mental health professional, or other provider shall not collect any amount from the patient for health care services or mental health services provided from the date the completed credentialing application was submitted to the carrier until the applicant received notification from the carrier that credentialing was denied.G\n\nNew provider applicants, in order to submit claims to the carrier pursuant to this section, shall provide written or electronic notice to covered persons in advance of treatment that they have submitted a credentialing application to the carrier of the covered person, stating that the carrier is in the process of obtaining and verifying the following pursuant to credentialing regulations:\n\t\t\t“Notice of Provider credentialing and re-credentialing.\n\t\t\tYour health insurance carrier is required to establish and maintain a comprehensive credentialing verification program to ensure that its physicians, mental health professionals, and other providers meet the minimum standards of professional licensure or certification. Written supporting documentation for (i) physicians, (ii) mental health professionals who have completed their residency or fellowship requirements for their specialty area more than 12 months prior to the credentialing decision, or (iii) other providers shall include:1\n\nCurrent valid license and history of licensure or certification;2\n\nStatus of hospital privileges, if applicable;3\n\nValid U.S. Drug Enforcement Administration certificate, if applicable;4\n\nInformation from the National Practitioner Data Bank, as available;5\n\nEducation and training, including postgraduate training, if applicable;6\n\nSpecialty board certification status, if applicable;7\n\nPractice or work history covering at least the past five years; and8\n\nCurrent, adequate malpractice insurance and malpractice history covering at least the past five years.\n\t\t\t\tYour health insurance carrier is in the process of obtaining and verifying the above information in order to determine if your physician, mental health professional, or other provider will be credentialed or not.”H\n\nThe provisions of this section shall not apply to coverages issued by a Medicare Advantage plan, but shall apply to health maintenance organizations that issue coverage pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid).I\n\nThe Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.","order_by":null,"text":{"0":{"id":241048,"text":"As used in this section:\n\t\t\t“Carrier” means an entity subject to the insurance laws and regulations of the Commonwealth and subject to the jurisdiction of the Commission that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services or mental health services, including an insurer licensed to sell accident and sickness insurance, a health maintenance organization, a health services plan, or any other entity providing a plan of health insurance, health benefits, health care services, or mental health services.\n\t\t\t“Covered person” means a policyholder, subscriber, enrollee, participant, or other individual covered by a health benefit plan.\n\t\t\t“Health benefit plan” means a policy, contract, certificate, or agreement offered by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.\n\t\t\t“Mental health professional” has the meaning ascribed thereto in § 54.1-2400.1.\n\t\t\t“Mental health services” means benefits with respect to items or services provided by mental health professionals for mental health conditions as defined under the terms of a health benefit plan.\n\t\t\t“Network” means a group of participating providers who provide health care services under the carrier’s health benefit plan that requires or creates incentives for a covered person to use the participating providers.\n\t\t\t“New provider applicant” means a physician, mental health professional, or other provider who has submitted a completed credentialing application to a carrier.\n\t\t\t“Other provider” means a person, corporation, facility, or institution licensed by the Commonwealth under Title 32.1 or 54.1 to provide health care or professional health-related services on a fee basis.\n\t\t\t“Participating mental health professional” means a mental health professional who is managed, under contract with, or employed by a carrier and who has agreed to provide health care services to covered persons with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier.\n\t\t\t“Participating other provider” means an other provider who is managed, under contract with, or employed by a carrier and who has agreed to provide such health care or professional services to covered persons with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier.\n\t\t\t“Participating physician” means a physician who is managed, under contract with, or employed by a carrier and who has agreed to provide health care services or mental health services to covered persons with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier.\n\t\t\t“Participating provider” means a participating physician, participating mental health professional, or participating other provider.\n\t\t\t“Physician” means a doctor of medicine or osteopathic medicine holding an active license from the Board of Medicine.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":241049,"text":"A carrier that credentials the physicians, mental health professionals, or other providers in its network shall establish reasonable protocols and procedures for processing new provider credentialing applications and reimbursing new provider applicants for health care services or mental health services provided to covered persons during the period in which an approved applicant’s completed credentialing application was pending. At a minimum, the protocols and procedures shall require the following:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":241050,"text":"If the carrier accepts applications through an online credentialing system, the carrier shall notify a new provider applicant through the online credentialing system that the provider has submitted and attested to the application as notice by the carrier that the application is received. If the carrier does not accept applications through an online credentialing system, the carrier shall within 10 days of receiving an application provide notification to the new provider applicant either by mail or electronic mail, as selected by the applicant, that the application was received;","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"3":{"id":241051,"text":"Beginning January 1, 2024, a new provider applicant’s application is deemed complete within 30 days of the carrier receiving the application, unless the carrier has provided notice that the application is not complete. Notice shall be provided by electronic mail unless the provider applicant has selected notification by mail;","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"B3"},"4":{"id":241052,"text":"The carrier shall approve or deny new provider applicant credentialing applications within 60 days of receiving a completed application;","type":"section","prefixes":["B","3"],"prefix":"3","entire_prefix":"B3","prefix_anchor":"B3","level":2,"prior_prefix":"B2","next_prefix":"B4"},"5":{"id":241053,"text":"Claims submitted according to carrier claims submittal policies for services rendered during the period of a pending application shall be adjudicated and paid no later than 40 days after the new provider applicant is credentialed and contracted;","type":"section","prefixes":["B","4"],"prefix":"4","entire_prefix":"B4","prefix_anchor":"B4","level":2,"prior_prefix":"B3","next_prefix":"B5"},"6":{"id":241054,"text":"The protocols and procedures shall apply only if a contractual relationship exists between the carrier and the new provider applicant or entity for whom the new provider applicant is employed or engaged; and","type":"section","prefixes":["B","5"],"prefix":"5","entire_prefix":"B5","prefix_anchor":"B5","level":2,"prior_prefix":"B4","next_prefix":"B6"},"7":{"id":241055,"text":"Any reimbursement shall be paid at the in-network rate that the new provider applicant would have received had he been, at the time the covered health care services were provided, a credentialed participating provider in the network for the applicable health benefit plan.","type":"section","prefixes":["B","6"],"prefix":"6","entire_prefix":"B6","prefix_anchor":"B6","level":2,"prior_prefix":"B5","next_prefix":"C"},"8":{"id":241056,"text":"Nothing in this section shall require reimbursement of the new provider applicant-rendered services that are not benefits or services covered by the carrier’s health benefit plan.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B6","next_prefix":"D"},"9":{"id":241057,"text":"Nothing in this section requires a carrier to pay reimbursement at the contracted in-network rate for any covered health care services or mental health services provided by the new provider applicant if the new provider applicant’s credentialing application is not approved or the carrier is otherwise not willing to contract with the new provider applicant.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"10":{"id":241058,"text":"Payments made or retroactive denials of payments made under this section shall be governed by § 38.2-3407.15.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"11":{"id":241059,"text":"If a payment is made by the carrier to a new provider applicant or any entity that employs or engages such new provider applicant under this section for a covered service, the patient shall only be responsible for any coinsurance, copayments, or deductibles permitted under the insurance contract with the carrier or participating provider agreement with the physician, mental health professional, or other provider. If the new provider applicant is not credentialed by the carrier, the new provider applicant or any entity that employs or engages such physician, mental health professional, or other provider shall not collect any amount from the patient for health care services or mental health services provided from the date the completed credentialing application was submitted to the carrier until the applicant received notification from the carrier that credentialing was denied.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"12":{"id":241060,"text":"New provider applicants, in order to submit claims to the carrier pursuant to this section, shall provide written or electronic notice to covered persons in advance of treatment that they have submitted a credentialing application to the carrier of the covered person, stating that the carrier is in the process of obtaining and verifying the following pursuant to credentialing regulations:\n\t\t\t“Notice of Provider credentialing and re-credentialing.\n\t\t\tYour health insurance carrier is required to establish and maintain a comprehensive credentialing verification program to ensure that its physicians, mental health professionals, and other providers meet the minimum standards of professional licensure or certification. Written supporting documentation for (i) physicians, (ii) mental health professionals who have completed their residency or fellowship requirements for their specialty area more than 12 months prior to the credentialing decision, or (iii) other providers shall include:","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"G1"},"13":{"id":241061,"text":"Current valid license and history of licensure or certification;","type":"section","prefixes":["G","1"],"prefix":"1","entire_prefix":"G1","prefix_anchor":"G1","level":2,"prior_prefix":"G","next_prefix":"G2"},"14":{"id":241062,"text":"Status of hospital privileges, if applicable;","type":"section","prefixes":["G","2"],"prefix":"2","entire_prefix":"G2","prefix_anchor":"G2","level":2,"prior_prefix":"G1","next_prefix":"G3"},"15":{"id":241063,"text":"Valid U.S. Drug Enforcement Administration certificate, if applicable;","type":"section","prefixes":["G","3"],"prefix":"3","entire_prefix":"G3","prefix_anchor":"G3","level":2,"prior_prefix":"G2","next_prefix":"G4"},"16":{"id":241064,"text":"Information from the National Practitioner Data Bank, as available;","type":"section","prefixes":["G","4"],"prefix":"4","entire_prefix":"G4","prefix_anchor":"G4","level":2,"prior_prefix":"G3","next_prefix":"G5"},"17":{"id":241065,"text":"Education and training, including postgraduate training, if applicable;","type":"section","prefixes":["G","5"],"prefix":"5","entire_prefix":"G5","prefix_anchor":"G5","level":2,"prior_prefix":"G4","next_prefix":"G6"},"18":{"id":241066,"text":"Specialty board certification status, if applicable;","type":"section","prefixes":["G","6"],"prefix":"6","entire_prefix":"G6","prefix_anchor":"G6","level":2,"prior_prefix":"G5","next_prefix":"G7"},"19":{"id":241067,"text":"Practice or work history covering at least the past five years; and","type":"section","prefixes":["G","7"],"prefix":"7","entire_prefix":"G7","prefix_anchor":"G7","level":2,"prior_prefix":"G6","next_prefix":"G8"},"20":{"id":241068,"text":"Current, adequate malpractice insurance and malpractice history covering at least the past five years.\n\t\t\t\tYour health insurance carrier is in the process of obtaining and verifying the above information in order to determine if your physician, mental health professional, or other provider will be credentialed or not.”","type":"section","prefixes":["G","8"],"prefix":"8","entire_prefix":"G8","prefix_anchor":"G8","level":2,"prior_prefix":"G7","next_prefix":"H"},"21":{"id":241069,"text":"The provisions of this section shall not apply to coverages issued by a Medicare Advantage plan, but shall apply to health maintenance organizations that issue coverage pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid).","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G8","next_prefix":"I"},"22":{"id":241070,"text":"The Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.","type":"section","prefixes":["I"],"prefix":"I","entire_prefix":"I","prefix_anchor":"I","level":1,"prior_prefix":"H"}},"ancestry":[{"id":12994,"edition_id":1,"name":"General Provisions","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214889,"object_type":"structure","relational_id":12994,"identifier":"1","token":"38.2\/34\/1","url":"\/38.2\/34\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12993,"edition_id":1,"name":"Provisions Relating to Accident and Sickness Insurance","identifier":"34","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214887,"object_type":"structure","relational_id":12993,"identifier":"34","token":"38.2\/34","url":"\/38.2\/34\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":57593,"structure_id":12994,"section_number":"38.2-3400","catch_line":"Application of chapter","url":"\/38.2-3400\/","token":"38.2\/34\/1\/38.2-3400","metadata":false},{"id":72072,"structure_id":12994,"section_number":"38.2-3401","catch_line":"Forms of insurance authorized","url":"\/38.2-3401\/","token":"38.2\/34\/1\/38.2-3401","metadata":false},{"id":65240,"structure_id":12994,"section_number":"38.2-3402","catch_line":"Certification to accompany application","url":"\/38.2-3402\/","token":"38.2\/34\/1\/38.2-3402","metadata":false},{"id":83988,"structure_id":12994,"section_number":"38.2-3403","catch_line":"Fraudulent procurement of policy","url":"\/38.2-3403\/","token":"38.2\/34\/1\/38.2-3403","metadata":false},{"id":65279,"structure_id":12994,"section_number":"38.2-3404","catch_line":"Commission may establish rules and regulations for simplified and readable accident and sickness insurance policies","url":"\/38.2-3404\/","token":"38.2\/34\/1\/38.2-3404","metadata":false},{"id":62539,"structure_id":12994,"section_number":"38.2-3405","catch_line":"Certain subrogation provisions and limitations upon recovery in hospital, medical, etc., policies forbidden; limitations on disclosure of medical treatment options prohibited","url":"\/38.2-3405\/","token":"38.2\/34\/1\/38.2-3405","metadata":false},{"id":84136,"structure_id":12994,"section_number":"38.2-3405.1","catch_line":"Commonwealth's right to certain accident and sickness benefits","url":"\/38.2-3405.1\/","token":"38.2\/34\/1\/38.2-3405.1","metadata":false},{"id":70730,"structure_id":12994,"section_number":"38.2-3406","catch_line":"Accident and sickness benefits not subject to legal process","url":"\/38.2-3406\/","token":"38.2\/34\/1\/38.2-3406","metadata":false},{"id":84333,"structure_id":12994,"section_number":"38.2-3406.1","catch_line":"Application of requirements that policies offered by small employers include state-mandated health benefits","url":"\/38.2-3406.1\/","token":"38.2\/34\/1\/38.2-3406.1","metadata":false},{"id":67972,"structure_id":12994,"section_number":"38.2-3406.2","catch_line":"Capped benefits under insurance policies and contracts","url":"\/38.2-3406.2\/","token":"38.2\/34\/1\/38.2-3406.2","metadata":false},{"id":76321,"structure_id":12994,"section_number":"38.2-3407","catch_line":"Health benefit programs","url":"\/38.2-3407\/","token":"38.2\/34\/1\/38.2-3407","metadata":false},{"id":66921,"structure_id":12994,"section_number":"38.2-3407.1","catch_line":"Interest on accident and sickness claim proceeds","url":"\/38.2-3407.1\/","token":"38.2\/34\/1\/38.2-3407.1","metadata":false},{"id":58079,"structure_id":12994,"section_number":"38.2-3407.10","catch_line":"Health care provider panels","url":"\/38.2-3407.10\/","token":"38.2\/34\/1\/38.2-3407.10","metadata":false},{"id":66411,"structure_id":12994,"section_number":"38.2-3407.10:1","catch_line":"Processing of new provider applications and reimbursement for services rendered during pendency of a participating provider's credentialing application","url":"\/38.2-3407.10_1\/","token":"38.2\/34\/1\/38.2-3407.10_1","metadata":false},{"id":56463,"structure_id":12994,"section_number":"38.2-3407.10:2","catch_line":"Credentialing of private mental health agencies","url":"\/38.2-3407.10_2\/","token":"38.2\/34\/1\/38.2-3407.10_2","metadata":false},{"id":82372,"structure_id":12994,"section_number":"38.2-3407.11","catch_line":"Access to obstetrician-gynecologists","url":"\/38.2-3407.11\/","token":"38.2\/34\/1\/38.2-3407.11","metadata":false},{"id":70024,"structure_id":12994,"section_number":"38.2-3407.11:1","catch_line":"Access to specialists; 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dentists and oral surgeons","url":"\/38.2-3407.13\/","token":"38.2\/34\/1\/38.2-3407.13","metadata":false},{"id":79541,"structure_id":12994,"section_number":"38.2-3407.13:1","catch_line":"Coordination of benefits; notice of priority of coverage","url":"\/38.2-3407.13_1\/","token":"38.2\/34\/1\/38.2-3407.13_1","metadata":false},{"id":87429,"structure_id":12994,"section_number":"38.2-3407.13:2","catch_line":"Claims paid to insureds for services from nonparticipating physicians","url":"\/38.2-3407.13_2\/","token":"38.2\/34\/1\/38.2-3407.13_2","metadata":false},{"id":60288,"structure_id":12994,"section_number":"38.2-3407.14","catch_line":"Notice of premium or deductible increases","url":"\/38.2-3407.14\/","token":"38.2\/34\/1\/38.2-3407.14","metadata":false},{"id":82945,"structure_id":12994,"section_number":"38.2-3407.14:1","catch_line":"Standard of clinical evidence for decisions on coverage for proton radiation therapy","url":"\/38.2-3407.14_1\/","token":"38.2\/34\/1\/38.2-3407.14_1","metadata":false},{"id":71060,"structure_id":12994,"section_number":"38.2-3407.15","catch_line":"Ethics and fairness in carrier business practices","url":"\/38.2-3407.15\/","token":"38.2\/34\/1\/38.2-3407.15","metadata":false},{"id":79973,"structure_id":12994,"section_number":"38.2-3407.15:1","catch_line":"Carrier contracts with pharmacy providers; required provisions; limit on termination or nonrenewal","url":"\/38.2-3407.15_1\/","token":"38.2\/34\/1\/38.2-3407.15_1","metadata":false},{"id":81930,"structure_id":12994,"section_number":"38.2-3407.15:2","catch_line":"(Effective January 1, 2027) Carrier contracts; required provisions regarding prior authorization for drug benefits","url":"\/38.2-3407.15_2\/","token":"38.2\/34\/1\/38.2-3407.15_2","metadata":false},{"id":77493,"structure_id":12994,"section_number":"38.2-3407.15:3","catch_line":"Carrier and intermediary contracts with pharmacy providers; disclosure and updating of maximum allowable cost of drugs; limit on termination or nonrenewal","url":"\/38.2-3407.15_3\/","token":"38.2\/34\/1\/38.2-3407.15_3","metadata":false},{"id":73491,"structure_id":12994,"section_number":"38.2-3407.15:4","catch_line":"Limit on copayment for prescription drugs; permitted disclosures","url":"\/38.2-3407.15_4\/","token":"38.2\/34\/1\/38.2-3407.15_4","metadata":false},{"id":57527,"structure_id":12994,"section_number":"38.2-3407.15:5","catch_line":"Limit on cost-sharing payments for prescription insulin drugs","url":"\/38.2-3407.15_5\/","token":"38.2\/34\/1\/38.2-3407.15_5","metadata":false},{"id":80337,"structure_id":12994,"section_number":"38.2-3407.15:6","catch_line":"Prescription drug price transparency","url":"\/38.2-3407.15_6\/","token":"38.2\/34\/1\/38.2-3407.15_6","metadata":false},{"id":87317,"structure_id":12994,"section_number":"38.2-3407.15:7","catch_line":"Carrier provision of certain information","url":"\/38.2-3407.15_7\/","token":"38.2\/34\/1\/38.2-3407.15_7","metadata":false},{"id":82040,"structure_id":12994,"section_number":"38.2-3407.15:8","catch_line":"(Effective January 1, 2027) Carrier contracts; required provisions regarding prior authorization for health care services","url":"\/38.2-3407.15_8\/","token":"38.2\/34\/1\/38.2-3407.15_8","metadata":false},{"id":76440,"structure_id":12994,"section_number":"38.2-3407.16","catch_line":"Requirements for obstetrical care","url":"\/38.2-3407.16\/","token":"38.2\/34\/1\/38.2-3407.16","metadata":false},{"id":64799,"structure_id":12994,"section_number":"38.2-3407.17","catch_line":"Payment for services by dentists and oral surgeons","url":"\/38.2-3407.17\/","token":"38.2\/34\/1\/38.2-3407.17","metadata":false},{"id":55530,"structure_id":12994,"section_number":"38.2-3407.17:1","catch_line":"Payment and reimbursement practices for dental services; network access","url":"\/38.2-3407.17_1\/","token":"38.2\/34\/1\/38.2-3407.17_1","metadata":false},{"id":81770,"structure_id":12994,"section_number":"38.2-3407.18","catch_line":"Requirements for orally administered cancer chemotherapy drugs","url":"\/38.2-3407.18\/","token":"38.2\/34\/1\/38.2-3407.18","metadata":false},{"id":83502,"structure_id":12994,"section_number":"38.2-3407.19","catch_line":"Payment for services by optometrists and ophthalmologists","url":"\/38.2-3407.19\/","token":"38.2\/34\/1\/38.2-3407.19","metadata":false},{"id":77646,"structure_id":12994,"section_number":"38.2-3407.2","catch_line":"Coverage for medical child support","url":"\/38.2-3407.2\/","token":"38.2\/34\/1\/38.2-3407.2","metadata":false},{"id":73127,"structure_id":12994,"section_number":"38.2-3407.20","catch_line":"Calculation of enrollee's contribution to out-of-pocket maximum or cost-sharing requirement","url":"\/38.2-3407.20\/","token":"38.2\/34\/1\/38.2-3407.20","metadata":false},{"id":57407,"structure_id":12994,"section_number":"38.2-3407.21","catch_line":"Short-term limited-duration medical plans","url":"\/38.2-3407.21\/","token":"38.2\/34\/1\/38.2-3407.21","metadata":false},{"id":85964,"structure_id":12994,"section_number":"38.2-3407.22","catch_line":"Option for rebates to enrollees; protected information","url":"\/38.2-3407.22\/","token":"38.2\/34\/1\/38.2-3407.22","metadata":false},{"id":81846,"structure_id":12994,"section_number":"38.2-3407.3","catch_line":"Calculation of cost-sharing provisions","url":"\/38.2-3407.3\/","token":"38.2\/34\/1\/38.2-3407.3","metadata":false},{"id":62583,"structure_id":12994,"section_number":"38.2-3407.3:1","catch_line":"Premium payment arrearages; order of crediting payments","url":"\/38.2-3407.3_1\/","token":"38.2\/34\/1\/38.2-3407.3_1","metadata":false},{"id":78457,"structure_id":12994,"section_number":"38.2-3407.4","catch_line":"Explanation of benefits","url":"\/38.2-3407.4\/","token":"38.2\/34\/1\/38.2-3407.4","metadata":false},{"id":72294,"structure_id":12994,"section_number":"38.2-3407.4:1","catch_line":"Repealed","url":"\/38.2-3407.4_1\/","token":"38.2\/34\/1\/38.2-3407.4_1","metadata":false},{"id":57129,"structure_id":12994,"section_number":"38.2-3407.4:2","catch_line":"Requirements for prescription benefit cards","url":"\/38.2-3407.4_2\/","token":"38.2\/34\/1\/38.2-3407.4_2","metadata":false},{"id":62057,"structure_id":12994,"section_number":"38.2-3407.5","catch_line":"Denial of benefits for certain prescription drugs prohibited","url":"\/38.2-3407.5\/","token":"38.2\/34\/1\/38.2-3407.5","metadata":false},{"id":54072,"structure_id":12994,"section_number":"38.2-3407.5:1","catch_line":"Coverage for prescription contraceptives","url":"\/38.2-3407.5_1\/","token":"38.2\/34\/1\/38.2-3407.5_1","metadata":false},{"id":79611,"structure_id":12994,"section_number":"38.2-3407.5:2","catch_line":"Reimbursements for dispensing hormonal contraceptives","url":"\/38.2-3407.5_2\/","token":"38.2\/34\/1\/38.2-3407.5_2","metadata":false},{"id":83778,"structure_id":12994,"section_number":"38.2-3407.6","catch_line":"Exclusion of podiatrist not permitted under certain circumstances","url":"\/38.2-3407.6\/","token":"38.2\/34\/1\/38.2-3407.6","metadata":false},{"id":74649,"structure_id":12994,"section_number":"38.2-3407.6:1","catch_line":"Denial of benefits for certain prescription drugs prohibited","url":"\/38.2-3407.6_1\/","token":"38.2\/34\/1\/38.2-3407.6_1","metadata":false},{"id":72641,"structure_id":12994,"section_number":"38.2-3407.7","catch_line":"Pharmacies; freedom of choice","url":"\/38.2-3407.7\/","token":"38.2\/34\/1\/38.2-3407.7","metadata":false},{"id":73400,"structure_id":12994,"section_number":"38.2-3407.8","catch_line":"Repealed","url":"\/38.2-3407.8\/","token":"38.2\/34\/1\/38.2-3407.8","metadata":false},{"id":72540,"structure_id":12994,"section_number":"38.2-3407.9","catch_line":"Reimbursement for emergency medical services vehicle transportation services","url":"\/38.2-3407.9\/","token":"38.2\/34\/1\/38.2-3407.9","metadata":false},{"id":62232,"structure_id":12994,"section_number":"38.2-3407.9:01","catch_line":"Prescription drug formularies","url":"\/38.2-3407.9_01\/","token":"38.2\/34\/1\/38.2-3407.9_01","metadata":false},{"id":62074,"structure_id":12994,"section_number":"38.2-3407.9:02","catch_line":"Requirement for prescription drug coverage","url":"\/38.2-3407.9_02\/","token":"38.2\/34\/1\/38.2-3407.9_02","metadata":false},{"id":68601,"structure_id":12994,"section_number":"38.2-3407.9:03","catch_line":"Payment of clean claims to administrators of pharmacy benefits","url":"\/38.2-3407.9_03\/","token":"38.2\/34\/1\/38.2-3407.9_03","metadata":false},{"id":56568,"structure_id":12994,"section_number":"38.2-3407.9:04","catch_line":"Medication synchronization","url":"\/38.2-3407.9_04\/","token":"38.2\/34\/1\/38.2-3407.9_04","metadata":false},{"id":71499,"structure_id":12994,"section_number":"38.2-3407.9:05","catch_line":"Step therapy protocols","url":"\/38.2-3407.9_05\/","token":"38.2\/34\/1\/38.2-3407.9_05","metadata":false}],"previous_section":{"id":58079,"structure_id":12994,"section_number":"38.2-3407.10","catch_line":"Health care provider panels","url":"\/38.2-3407.10\/","token":"38.2\/34\/1\/38.2-3407.10","metadata":false},"next_section":{"id":56463,"structure_id":12994,"section_number":"38.2-3407.10:2","catch_line":"Credentialing of private mental health agencies","url":"\/38.2-3407.10_2\/","token":"38.2\/34\/1\/38.2-3407.10_2","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3407.10:1\/","history_text":"

This law was first created in 2018. The record of its establishment is cataloged in chapter 703<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. It has been modified 4 times. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. Those modifications are as follows: in 2019, chapter 689<\/a>; in 2020, chapter 840<\/a>; in 2022, chapters 471<\/a> and 472<\/a>; in 2023, chapters 376<\/a> and 377<\/a>.<\/p>","references":[{"id":56463,"section_number":"38.2-3407.10:2","catch_line":"Credentialing of private mental health agencies","order_by":null,"url":"\/38.2-3407.10_2\/"},{"id":67952,"section_number":"38.2-4319","catch_line":"Statutory construction and relationship to other laws","order_by":null,"url":"\/38.2-4319\/"},{"id":62548,"section_number":"38.2-4509","catch_line":"Application of certain laws","order_by":null,"url":"\/38.2-4509\/"}],"refers_to":[{"id":69157,"section_number":"54.1-2400.1","catch_line":"Mental health service providers; duty to protect third parties; immunity","order_by":null,"url":"\/54.1-2400.1\/"}],"permalink":{"id":214943,"object_type":"law","relational_id":66411,"identifier":"38.2-3407.10:1","token":"38.2\/34\/1\/38.2-3407.10_1","url":"\/38.2-3407.10_1\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.10_1\/","token":"38.2\/34\/1\/38.2-3407.10_1","dublin_core":{"Title":"Processing of new provider applications and reimbursement for services rendered during pendency of a participating provider’s credentialing application","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.10:1","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section:\n\t\t\t“Carrier<\/span>” means an entity subject to the insurance<\/span> laws<\/span> and regulations of the Commonwealth and subject to the jurisdiction<\/span> of the Commission<\/span> that contracts<\/span> or offers to contract<\/span> to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services or mental health services<\/span>, including an insurer<\/span> licensed to sell accident and sickness insurance<\/span>, a health maintenance organization, a health services plan<\/span>, or any other entity providing a plan of health insurance<\/span>, health benefits, health care services, or mental health services<\/span>.\n\t\t\t“Covered person<\/span>” means a policyholder, subscriber, enrollee, participant, or other individual covered by a health benefit plan<\/span>.\n\t\t\t“Health benefit plan<\/span>” means a policy, contract<\/span>, certificate, or agreement offered by a carrier<\/span> to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.\n\t\t\t“Mental health professional” has the meaning ascribed thereto in § 54.1-2400.1<\/a>.\n\t\t\t“Mental health services<\/span>” means benefits with respect to items or services provided by mental health professionals for mental health conditions as defined under the terms of a health benefit plan<\/span>.\n\t\t\t“Network<\/span>” means a group of participating providers<\/span> who provide health care services under the carrier<\/span>’s health benefit plan<\/span> that requires or creates incentives for a covered person<\/span> to use the participating providers<\/span>.\n\t\t\t“New provider applicant<\/span>” means a physician, mental health professional, or other provider who has submitted a completed credentialing application to a carrier<\/span>.\n\t\t\t“Other provider” means a person, corporation, facility, or institution licensed by the Commonwealth under Title 32.1 or 54.1 to provide health care or professional health-related services on a fee basis.\n\t\t\t“Participating mental health professional<\/span>” means a mental health professional who is managed, under contract<\/span> with, or employed by a carrier<\/span> and who has agreed to provide health care services to covered persons<\/span> with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier<\/span>.\n\t\t\t“Participating other provider<\/span>” means an other provider who is managed, under contract<\/span> with, or employed by a carrier<\/span> and who has agreed to provide such health care or professional services to covered persons<\/span> with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier<\/span>.\n\t\t\t“Participating physician<\/span>” means a physician who is managed, under contract<\/span> with, or employed by a carrier<\/span> and who has agreed to provide health care services or mental health services<\/span> to covered persons<\/span> with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the carrier<\/span>.\n\t\t\t“Participating provider<\/span>” means a participating physician<\/span>, participating mental health professional<\/span>, or participating other provider<\/span>.\n\t\t\t“Physician” means a doctor of medicine or osteopathic medicine holding an active license from the Board of Medicine. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> A carrier<\/span> that credentials the physicians<\/span>, mental health professionals, or other providers<\/span> in its network<\/span> shall establish reasonable protocols and procedures for processing new provider credentialing applications and reimbursing new provider applicants<\/span> for health care services or mental health services<\/span> provided to covered persons<\/span> during the period in which an approved applicant’s completed credentialing application was pending. At a minimum, the protocols and procedures shall require the following: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> If the carrier<\/span> accepts applications through an online credentialing system, the carrier<\/span> shall notify a new provider applicant<\/span> through the online credentialing system that the provider has submitted and attested to the application as notice by the carrier<\/span> that the application is received. If the carrier<\/span> does not accept applications through an online credentialing system, the carrier<\/span> shall within 10 days of receiving an application provide notification to the new provider applicant<\/span> either by mail or electronic mail, as selected by the applicant, that the application was received; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Beginning January 1, 2024, a new provider applicant<\/span>’s application is deemed complete within 30 days of the carrier<\/span> receiving the application, unless the carrier<\/span> has provided notice that the application is not complete. Notice shall be provided by electronic mail unless the provider applicant has selected notification by mail; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> The carrier<\/span> shall approve or deny new provider applicant<\/span> credentialing applications within 60 days of receiving a completed application; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Claims submitted according to carrier<\/span> claims submittal policies for services rendered during the period of a pending application shall be adjudicated and paid no later than 40 days after the new provider applicant<\/span> is credentialed and contracted; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> The protocols and procedures shall apply only if a contractual relationship exists between the carrier<\/span> and the new provider applicant<\/span> or entity for whom the new provider applicant<\/span> is employed or engaged; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

6.<\/span> Any reimbursement shall be paid at the in-network<\/span> rate<\/span> that the new provider applicant<\/span> would have received had he been, at the time the covered health care services were provided, a credentialed participating provider<\/span> in the network<\/span> for the applicable health benefit plan<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Nothing in this section shall require reimbursement of the new provider applicant<\/span>-rendered services that are not benefits or services covered by the carrier<\/span>’s health benefit plan<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Nothing in this section requires a carrier<\/span> to pay reimbursement at the contracted in-network<\/span> rate<\/span> for any covered health care services or mental health services<\/span> provided by the new provider applicant<\/span> if the new provider applicant<\/span>’s credentialing application is not approved or the carrier<\/span> is otherwise not willing to contract<\/span> with the new provider applicant<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Payments made or retroactive denials of payments made under this section shall be governed by § 38.2-3407.15<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> If a payment is made by the carrier<\/span> to a new provider applicant<\/span> or any entity that employs or engages such new provider applicant<\/span> under this section for a covered service, the patient shall only be responsible for any coinsurance, copayments, or deductibles permitted under the insurance<\/span> contract<\/span> with the carrier<\/span> or participating provider<\/span> agreement with the physician, mental health professional, or other provider. If the new provider applicant<\/span> is not credentialed by the carrier<\/span>, the new provider applicant<\/span> or any entity that employs or engages such physician, mental health professional, or other provider shall not collect any amount from the patient for health care services or mental health services<\/span> provided from the date the completed credentialing application was submitted to the carrier<\/span> until the applicant received notification from the carrier<\/span> that credentialing was denied. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> New provider applicants<\/span>, in order<\/span> to submit claims to the carrier<\/span> pursuant to this section, shall provide written or electronic notice to covered persons<\/span> in advance of treatment that they have submitted a credentialing application to the carrier<\/span> of the covered person<\/span>, stating that the carrier<\/span> is in the process of obtaining and verifying the following pursuant to credentialing regulations:\n\t\t\t“Notice of Provider credentialing and re-credentialing.\n\t\t\tYour health insurance<\/span> carrier<\/span> is required to establish and maintain a comprehensive credentialing verification program to ensure that its physicians<\/span>, mental health professionals, and other providers<\/span> meet the minimum standards of professional licensure or certification. Written supporting documentation for (i) physicians<\/span>, (ii) mental health professionals who have completed their residency or fellowship requirements for their specialty area more than 12 months prior to the credentialing decision, or (iii) other providers<\/span> shall include: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Current valid license and history of licensure or certification; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Status of hospital privileges<\/span>, if applicable; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Valid U.S. Drug Enforcement Administration certificate, if applicable; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Information from the National Practitioner Data Bank, as available; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> Education and training, including postgraduate training, if applicable; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

6.<\/span> Specialty board certification status, if applicable; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

7.<\/span> Practice or work history covering at least the past five years; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

8.<\/span> Current, adequate malpractice insurance<\/span> and malpractice history covering at least the past five years.\n\t\t\t\tYour health insurance<\/span> carrier<\/span> is in the process of obtaining and verifying the above information in order<\/span> to determine if your physician, mental health professional, or other provider will be credentialed or not.” <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> The provisions of this section shall not apply to coverages issued by a Medicare<\/span> Advantage plan, but shall apply to health maintenance organizations that issue<\/span> coverage pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid). <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

I.<\/span> The Commission<\/span> shall have no jurisdiction<\/span> to adjudicate<\/span> individual controversies arising out of this section. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nPROCESSING OF NEW PROVIDER APPLICATIONS AND REIMBURSEMENT FOR SERVICES RENDERED\nDURING PENDENCY OF A PARTICIPATING PROVIDER’S CREDENTIALING APPLICATION\n(\u00a7 38.2-3407.10:1)\n\nA. As used in this section:\n\t\t\t“Carrier” means an entity subject to the insurance laws and\nregulations of the Commonwealth and subject to the jurisdiction of the\nCommission that contracts or offers to contract to provide, deliver, arrange\nfor, pay for, or reimburse any of the costs of health care services or mental\nhealth services, including an insurer licensed to sell accident and sickness\ninsurance, a health maintenance organization, a health services plan, or any\nother entity providing a plan of health insurance, health benefits, health care\nservices, or mental health services.\n\t\t\t“Covered person” means a policyholder, subscriber, enrollee,\nparticipant, or other individual covered by a health benefit plan.\n\t\t\t“Health benefit plan” means a policy, contract, certificate, or\nagreement offered by a carrier to provide, deliver, arrange for, pay for, or\nreimburse any of the costs of health care services.\n\t\t\t“Mental health professional” has the meaning ascribed thereto in\n§ 54.1-2400.1.\n\t\t\t“Mental health services” means benefits with respect to items or\nservices provided by mental health professionals for mental health conditions as\ndefined under the terms of a health benefit plan.\n\t\t\t“Network” means a group of participating providers who provide\nhealth care services under the carrier’s health benefit plan that requires\nor creates incentives for a covered person to use the participating providers.\n\t\t\t“New provider applicant” means a physician, mental health\nprofessional, or other provider who has submitted a completed credentialing\napplication to a carrier.\n\t\t\t“Other provider” means a person, corporation, facility, or\ninstitution licensed by the Commonwealth under Title 32.1 or 54.1 to provide\nhealth care or professional health-related services on a fee basis.\n\t\t\t“Participating mental health professional” means a mental health\nprofessional who is managed, under contract with, or employed by a carrier and\nwho has agreed to provide health care services to covered persons with an\nexpectation of receiving payments, other than coinsurance, copayments, or\ndeductibles, directly or indirectly from the carrier.\n\t\t\t“Participating other provider” means an other provider who is\nmanaged, under contract with, or employed by a carrier and who has agreed to\nprovide such health care or professional services to covered persons with an\nexpectation of receiving payments, other than coinsurance, copayments, or\ndeductibles, directly or indirectly from the carrier.\n\t\t\t“Participating physician” means a physician who is managed, under\ncontract with, or employed by a carrier and who has agreed to provide health\ncare services or mental health services to covered persons with an expectation\nof receiving payments, other than coinsurance, copayments, or deductibles,\ndirectly or indirectly from the carrier.\n\t\t\t“Participating provider” means a participating physician,\nparticipating mental health professional, or participating other provider.\n\t\t\t“Physician” means a doctor of medicine or osteopathic medicine\nholding an active license from the Board of Medicine.\n\nB. A carrier that credentials the physicians, mental health professionals, or\nother providers in its network shall establish reasonable protocols and\nprocedures for processing new provider credentialing applications and\nreimbursing new provider applicants for health care services or mental health\nservices provided to covered persons during the period in which an approved\napplicant’s completed credentialing application was pending. At a minimum,\nthe protocols and procedures shall require the following:\n\n 1. If the carrier accepts applications through an online credentialing system,\n the carrier shall notify a new provider applicant through the online\n credentialing system that the provider has submitted and attested to the\n application as notice by the carrier that the application is received. If the\n carrier does not accept applications through an online credentialing system,\n the carrier shall within 10 days of receiving an application provide\n notification to the new provider applicant either by mail or electronic mail,\n as selected by the applicant, that the application was received;\n\n 2. Beginning January 1, 2024, a new provider applicant’s application is\n deemed complete within 30 days of the carrier receiving the application,\n unless the carrier has provided notice that the application is not complete.\n Notice shall be provided by electronic mail unless the provider applicant has\n selected notification by mail;\n\n 3. The carrier shall approve or deny new provider applicant credentialing\n applications within 60 days of receiving a completed application;\n\n 4. Claims submitted according to carrier claims submittal policies for\n services rendered during the period of a pending application shall be\n adjudicated and paid no later than 40 days after the new provider applicant is\n credentialed and contracted;\n\n 5. The protocols and procedures shall apply only if a contractual relationship\n exists between the carrier and the new provider applicant or entity for whom\n the new provider applicant is employed or engaged; and\n\n 6. Any reimbursement shall be paid at the in-network rate that the new\n provider applicant would have received had he been, at the time the covered\n health care services were provided, a credentialed participating provider in\n the network for the applicable health benefit plan.\n\nC. Nothing in this section shall require reimbursement of the new provider\napplicant-rendered services that are not benefits or services covered by the\ncarrier’s health benefit plan.\n\nD. Nothing in this section requires a carrier to pay reimbursement at the\ncontracted in-network rate for any covered health care services or mental health\nservices provided by the new provider applicant if the new provider\napplicant’s credentialing application is not approved or the carrier is\notherwise not willing to contract with the new provider applicant.\n\nE. Payments made or retroactive denials of payments made under this section\nshall be governed by § 38.2-3407.15.\n\nF. If a payment is made by the carrier to a new provider applicant or any entity\nthat employs or engages such new provider applicant under this section for a\ncovered service, the patient shall only be responsible for any coinsurance,\ncopayments, or deductibles permitted under the insurance contract with the\ncarrier or participating provider agreement with the physician, mental health\nprofessional, or other provider. If the new provider applicant is not\ncredentialed by the carrier, the new provider applicant or any entity that\nemploys or engages such physician, mental health professional, or other provider\nshall not collect any amount from the patient for health care services or mental\nhealth services provided from the date the completed credentialing application\nwas submitted to the carrier until the applicant received notification from the\ncarrier that credentialing was denied.\n\nG. New provider applicants, in order to submit claims to the carrier pursuant to\nthis section, shall provide written or electronic notice to covered persons in\nadvance of treatment that they have submitted a credentialing application to the\ncarrier of the covered person, stating that the carrier is in the process of\nobtaining and verifying the following pursuant to credentialing regulations:\n\t\t\t“Notice of Provider credentialing and re-credentialing.\n\t\t\tYour health insurance carrier is required to establish and maintain a\ncomprehensive credentialing verification program to ensure that its physicians,\nmental health professionals, and other providers meet the minimum standards of\nprofessional licensure or certification. Written supporting documentation for\n(i) physicians, (ii) mental health professionals who have completed their\nresidency or fellowship requirements for their specialty area more than 12\nmonths prior to the credentialing decision, or (iii) other providers shall\ninclude:\n\n 1. Current valid license and history of licensure or certification;\n\n 2. Status of hospital privileges, if applicable;\n\n 3. Valid U.S. Drug Enforcement Administration certificate, if applicable;\n\n 4. Information from the National Practitioner Data Bank, as available;\n\n 5. Education and training, including postgraduate training, if applicable;\n\n 6. Specialty board certification status, if applicable;\n\n 7. Practice or work history covering at least the past five years; and\n\n 8. Current, adequate malpractice insurance and malpractice history covering at\n least the past five years.\n \t\t\t\tYour health insurance carrier is in the process of obtaining and verifying\n the above information in order to determine if your physician, mental health\n professional, or other provider will be credentialed or not.”\n\nH. The provisions of this section shall not apply to coverages issued by a\nMedicare Advantage plan, but shall apply to health maintenance organizations\nthat issue coverage pursuant to Title XIX of the Social Security Act, 42 U.S.C.\n§ 1396 et seq. (Medicaid).\n\nI. The Commission shall have no jurisdiction to adjudicate individual\ncontroversies arising out of this section.\n\nHISTORY: 2018, c. 703; 2019, c. 689; 2020, c. 840; 2022, cc. 471, 472; 2023, cc.\n376, 377.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}