Uniform Group Practice Provider Credentialing

nc-stampSB 609 – Uniform Group Practice Provider Credentialing

Primary Sponsor: Sen. Rick Gunn (R – Alamance)

This bill would change the uniform provider credentialing statute to account for the credentialing of health care practitioners who join a group practice that has an existing contract with a health insurer.

This bill states that if an insurer has an existing contract with a group practice to participate in a health benefit plan, that the insurer would provide to the group practice a list of all information required for credentialing a new provider.

All of the following would apply to the credentialing process for a new health practitioner that joins a group practice with an existing contract with an insurer to participate in a health benefit plan.

  • Insurer shall notify new applicant in writing the status of the application no more than 5 days after receiving the application
    • This notice would state if the application is complete or incomplete.
    • If incomplete, the notice shall indicate what other information is needed.
    • If incomplete, the practitioner would have 30 calendar days to supply the information.
  • If the practitioner does not submit a credentialing application to an insurer within 30 calendar days, the application would be denied.
  • Insurers shall notify the new practitioner of the results within 60 days of receiving the application.
  • During the application process, an applicant could not submit any claims for reimbursement to the insurer for covered services provided by the applicant.
  • After the application is approved, all claims should be submitted to the insurer, and the insurer would pay the claims at the contracted in-network rate for any covered services.

This bill would become effective on October 1, 2017.


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