§ 23-99-411 - Processing applications of providers.
23-99-411. Processing applications of providers.
(a) (1) (A) Health care insurers shall establish mechanisms to ensure timely processing of requests for participation or renewal by providers and in making decisions that affect participation status.
(B) These mechanisms shall include, at a minimum, provisions for the provider to receive a written statement of reasons for the health care insurer's denial of a request for initial participation or renewal.
(2) (A) Health care insurers shall make a decision within:
(i) Ninety (90) calendar days from the date of submission of a completed application as defined by rule of the Insurance Commissioner for participation or a request for renewal by a physician licensed under the Arkansas Medical Practices Act, 17-95-201 et seq., 17-95-301 et seq., and 17-95-401 et seq.; and
(ii) One hundred eighty (180) calendar days from the date of submission of a completed application as defined by rule of the commissioner for participation or a request for renewal by any other provider.
(B) However, when a physician's credentials are verified through the Arkansas State Medical Board's Centralized Credentials Verification Service under 17-95-107, the ninety (90) days specified under subdivision (a)(2)(A)(i) of this section is tolled from the date an order is received by the Centralized Credentials Verification Service from the health care insurer until the date the health care insurer receives notification by the Centralized Credentials Verification Service that the file is complete and available for retrieval.
(C) (i) If the information provided by the initial application, the health care insurer's investigation, or the Centralized Credentials Verification Service requires the health care insurer to collect more detailed information from the provider to fairly and responsibly process the application, the time specified under subdivision (a)(2)(A)(i) of this section is tolled and the application is suspended from the date a written request for the information is sent to the provider until the request is fully and completely answered and sent to the health care insurer by the provider.
(ii) If the request is not fully answered within ninety (90) days of the date it was sent, the health care insurer, in its discretion, may treat the application as abandoned and deny it.
(iii) The request and response under this section shall be sent by regular mail or other means of delivery as may be allowed by rules adopted by the commissioner.
(3) If a physician is already credentialed by the health insurer but changes employment or changes location, the health insurer shall only require the submission of such additional information, if any, as is necessary to continue the physician's credentials based upon the changed employment or location.
(4) Health care insurers shall promptly notify providers:
(A) Of any delay in processing applications; and
(B) The reasons for a delay in processing applications.
(5) The commissioner may adopt rules to ensure that covered health care claims submitted by patients or their providers are not negatively affected by delays in processing participation applications.
(6) The commissioner shall adopt rules to implement this subsection.
(b) Nothing in this section shall prevent a provider or a health care insurer from terminating a participating provider contract in accordance with its terms.