                                 CODE OF VIRGINIA

PROCESSING OF NEW PROVIDER APPLICATIONS AND REIMBURSEMENT FOR SERVICES RENDERED
DURING PENDENCY OF A PARTICIPATING PROVIDER&#8217;S CREDENTIALING APPLICATION
(§ 38.2-3407.10:1)

A. As used in this section:
			&#8220;Carrier&#8221; 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.
			&#8220;Covered person&#8221; means a policyholder, subscriber, enrollee,
participant, or other individual covered by a health benefit plan.
			&#8220;Health benefit plan&#8221; 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.
			&#8220;Mental health professional&#8221; has the meaning ascribed thereto in
&#xA7; 54.1-2400.1.
			&#8220;Mental health services&#8221; 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.
			&#8220;Network&#8221; means a group of participating providers who provide
health care services under the carrier&#8217;s health benefit plan that requires
or creates incentives for a covered person to use the participating providers.
			&#8220;New provider applicant&#8221; means a physician, mental health
professional, or other provider who has submitted a completed credentialing
application to a carrier.
			&#8220;Other provider&#8221; 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.
			&#8220;Participating mental health professional&#8221; 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.
			&#8220;Participating other provider&#8221; 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.
			&#8220;Participating physician&#8221; 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.
			&#8220;Participating provider&#8221; means a participating physician,
participating mental health professional, or participating other provider.
			&#8220;Physician&#8221; means a doctor of medicine or osteopathic medicine
holding an active license from the Board of Medicine.

B. 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&#8217;s completed credentialing application was pending. At a minimum,
the protocols and procedures shall require the following:

   1. 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;

   2. Beginning January 1, 2024, a new provider applicant&#8217;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. The carrier shall approve or deny new provider applicant credentialing
   applications within 60 days of receiving a completed application;

   4. 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;

   5. 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

   6. 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.

C. Nothing in this section shall require reimbursement of the new provider
applicant-rendered services that are not benefits or services covered by the
carrier&#8217;s health benefit plan.

D. 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&#8217;s credentialing application is not approved or the carrier is
otherwise not willing to contract with the new provider applicant.

E. Payments made or retroactive denials of payments made under this section
shall be governed by &#xA7; 38.2-3407.15.

F. 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.

G. 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:
			&#8220;Notice of Provider credentialing and re-credentialing.
			Your 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. Current valid license and history of licensure or certification;

   2. Status of hospital privileges, if applicable;

   3. Valid U.S. Drug Enforcement Administration certificate, if applicable;

   4. Information from the National Practitioner Data Bank, as available;

   5. Education and training, including postgraduate training, if applicable;

   6. Specialty board certification status, if applicable;

   7. Practice or work history covering at least the past five years; and

   8. Current, adequate malpractice insurance and malpractice history covering at
   least the past five years.
   				Your 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.&#8221;

H. 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.
&#xA7; 1396 et seq. (Medicaid).

I. The Commission shall have no jurisdiction to adjudicate individual
controversies arising out of this section.

HISTORY: 2018, c. 703; 2019, c. 689; 2020, c. 840; 2022, cc. 471, 472; 2023, cc.
376, 377.