Credentialing Standards   /   January 2020

State-by-State Series, Part II: The Newbies – Arizona & Pennsylvania

State-by-State Series, Part II: The Newbies – Arizona & Pennsylvania

This week, we’re continuing our discussions of state-specific credentialing mandates. Today we’ll focus on two states with evolving requirements: Arizona, and Pennsylvania. Arizona has a new requirement that came into effect on December 31, 2019, and PA has House Bill 533 pending approval. We’ll spend this blog post providing details about the changes that were made in each of these states. Let’s dive right in!

 

Arizona

  • The state of Arizona required health insurers to establish a process for Electronic Application Submission and supporting documentation by December 31, 2019.  
    • It is further required that the Credentialing process must be completed within ninety (90) days of receipt of a clean, complete application, and the provider(s) must be loaded in their billing system one hundred days after receipt of the complete application.  
    • A written or electronic acknowledgment is required within seven days of receipt of the provider’s application for both a complete or incomplete application.  If the application is incomplete, the notification should indicate the information that is required to complete the credentialing process.  
    • The credentialing time periods are suspended until the information is received.  If the information is not received after thirty days then the application can be deemed withdrawn.  
    • If the notice is not sent within the seven-day timeframe, the application is considered complete. The health insurer shall send the applicant a complete contract ready for execution upon receipt of a complete application.
  • The Health Insurer is required to post nonproprietary credentialing information on their website, including their policy and procedures,  a list of all information required to be included with the application, a checklist of materials that must be submitted, and designated contact information for any credentialing-related questions. 
  • After the credentialing process is complete, the Health Insurer will make all non-proprietary information pertaining to a Provider Credentialing application and final decision available to the applicant upon request, if allowed by law.
  • Unless a provider’s credentialing data changes significantly, a health care entity will re-credential a provider at least once every 36 months or more frequently if required by Federal/State law/Accreditation or if the Standards/Contract arrangement with provider state a shorter time-frame.

Pennsylvania

  • PA’s House Bill 533 has passed the House and is moving to the Senate. This bill provides the use of the CAQH credentialing application (or other form) designated by the Insurance Department by all insurers for credentialing purposes. The credentialing application shall be deemed complete if submitted by the provider electronically and all of the required information is provided.
  • The insurer shall issue a credentialing determination within 60 days of receiving the complete application.
  • It is important to note that this act does not guarantee the rights of the practitioner to participate in any health network nor require a health network to accept any willing provider to an insurance network. 

CredSimple will continue to keep you updated on these and other updates nationally, for more on credentialing standards, check out our recent post on states with unique credentialing requirements.

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