Rhode Island General Laws 27-41-87. Healthcare provider credentialing
(a) For applications received on or after January 1, 2018, a healthcare entity or health plan operating in the state shall be required to issue a decision regarding the credentialing of a healthcare provider as soon as practicable, but no later than forty-five (45) calendar days after the date of receipt of a complete credentialing application.
Terms Used In Rhode Island General Laws 27-41-87
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Health maintenance organization: means a single public or private organization that:
(i) Provides or makes available to enrolled participants healthcare services, including at least the following basic healthcare services: usual physician services, hospitalization, laboratory, x-ray, emergency, and preventive services, and out-of-area coverage, and the services of licensed midwives;
(ii) Is compensated, except for copayments, for the provision of the basic healthcare services listed in subsection (20)(i) of this section to enrolled participants on a predetermined periodic rate basis;
(iii)(A) Provides physicians' services primarily:
(I) Directly through physicians who are either employees or partners of the organization; or
(II) Through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice basis;
(B) "Health maintenance organization" does not include prepaid plans offered by entities regulated under chapter 1, 2, 19, or 20 of this title that do not meet the criteria above and do not purport to be health maintenance organizations; and
(iv) Provides the services of licensed midwives primarily:
(A) Directly through licensed midwives who are either employees or partners of the organization; or
(B) Through arrangements with individual licensed midwives or one or more groups of licensed midwives organized on a group practice or individual practice basis. See Rhode Island General Laws 27-41-2
- Healthcare professional: means a physician or other healthcare practitioner licensed, accredited, or certified to perform specified healthcare services consistent with state law. See Rhode Island General Laws 27-41-2
- Healthcare services: means any services included in the furnishing to any individual of medical, podiatric, or dental care, or hospitalization, or incident to the furnishing of that care or hospitalization, and the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability. See Rhode Island General Laws 27-41-2
- in writing: include printing, engraving, lithographing, and photo-lithographing, and all other representations of words in letters of the usual form. See Rhode Island General Laws 43-3-16
- provider: means a healthcare professional or a healthcare facility. See Rhode Island General Laws 27-41-2
(b) For minor changes to the demographic information of an individual healthcare provider who is already credentialed with a particular healthcare entity or health plan, the healthcare entity or health plan shall complete the change within seven (7) business days of receipt of the healthcare provider’s request. Minor changes to demographic information requested by individual providers shall be submitted in the time frame, and manner required by the healthcare entity or health plan, and shall include all supporting documentation required by the particular healthcare entity or health plan. For purposes of this section, minor changes to the information profile of a healthcare provider shall include, but not be limited to, changes of address and changes to a healthcare provider’s tax identification number.
(c) Each healthcare entity or health plan shall establish a written standard defining what elements constitute a complete credentialing application and shall distribute this standard with the written version of the credentialing application and make the standard available on the healthcare entity’s or health plan’s website.
(d) Each healthcare entity or health plan shall respond to inquiries by the applicant regarding the status of an application.
(1) Each healthcare entity or health plan shall provide the applicant with automated application status updates, at least once every fifteen (15) calendar days, informing the applicant of any missing application materials until the application is deemed complete;
(2) Each healthcare entity or health plan shall inform the applicant within five (5) business days that the credentialing application is complete; and
(3) If the healthcare entity or health plan denies a credentialing application, the healthcare entity or health plan shall notify the healthcare provider in writing and shall provide the healthcare provider with any and all reasons for denying the credentialing application.
(e) The effective date for billing privileges for healthcare providers under a particular healthcare entity or health plan shall be the next business day following the date of approval of the credentialing application.
(f) For applications received from resident graduates on or after January 1, 2018, a healthcare entity or health plan shall offer a transitional or conditional approval process such that a resident graduate who has submitted an otherwise complete application and met all other criteria, may be conditionally approved, effective upon successful graduation from the training program.
(g) For the purposes of this section, the following definitions apply:
(1) “Complete credentialing application” means all the requested material has been submitted.
(2) “Date of receipt” means the date the healthcare entity or health plan receives the completed credentialing application whether via electronic submission or as a paper application.
(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or medical or dental service corporation or plan or health maintenance organization, or a contractor as defined in § 23-17.13-2 [repealed] that operates a health plan.
(4) “Healthcare provider” means a healthcare professional.
(5) “Health plan” means a plan operated by a healthcare entity that provides for the delivery of healthcare services to persons enrolled in those plans through:
(i) Arrangements with selected providers to furnish healthcare services; and
(ii) Financial incentives for persons enrolled in the plan to use the participating providers and procedures provided for by the health plan.
History of Section.
P.L. 2017, ch. 185, § 4; P.L. 2017, ch. 254, § 4.