New Jersey-2024-S3799-Introduced

An Act concerning the credentialing of physicians for a carrier's provider network, amending P.L.2001, c.88, and amending and supplementing P.L.1997, c.192.

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. Section 7 of P.L.1997, c.192 (C.26:2S-7) is amended to read as follows:

7. a. Each application for participation or renewal by a licensed health care professional that is submitted to a carrier which offers a managed care plan shall be reviewed by a committee of the carrier that includes appropriate representation of health care professional with knowledge in the applicant's scope of professional practice.

b. If the committee is reviewing a universal physician application for participation form or renewal form pursuant to section 1 of P.L.2001, c.88 (C.26:2S-7.1), the committee shall notify the applicant within 30 days following submission of the application whether the application is incomplete, with the committee specifying in writing to the applicant the specific information that is missing. If the committee does not notify the applicant of an incomplete application within 30 days, the application shall be deemed complete. The committee shall review a complete application for participation or renewal within 30 days of receipt of the completed application.

(cf: P.L.1997, c.192, s.7)

2. Section 2 of P.L.2001, c.88 (C.26:2S-7.2) is amended to read as follows:

2. [Within 180 days of the adoption of the forms by regulation pursuant to this act, a] a. A carrier which offers a managed care plan in this State shall accept the universal physician application for participation form and renewal form adopted pursuant to this act for the purpose of credentialing physicians who seek to participate in the carrier's provider network and for the purpose of credentialing physicians who are employed by hospitals or other health care facilities which seek to participate in the carrier's provider network. A carrier shall make available on the carrier's Internet website the universal participation and renewal forms and an explanation of the credentialing process, including a list of all the documents required for participation and renewal and any relevant timelines.

b. Nothing in this section shall be construed to prevent a carrier from requesting additional information from an applicant that is not provided for in the universal application or renewal form, as applicable, if the requested information does not duplicate any information included in the applicable form.

(cf: P.L.2001, c.88, s.2)

3. (New section) If a physician, while waiting to receive a credential to participate in the provider network of a carrier, is delivering health care services to covered persons within the network, the carrier shall reimburse the physician for services delivered as of the date the credentialing application was filed, if the application is approved by the carrier.

4. (New section) No carrier shall require a physician, who is already credentialed with the carrier and who changes employers or health care facilities within this State, to submit a new application or renewal form to participate in the carrier's network solely on the basis that the physician changed employers or health care facilities.

5. (New section) a. A health care professional pursuing a credential to join a carrier's provider network may report to the department any suspected violation of the provisions of P.L.1997, c.192 (C.26:2S-1 et al.) or P.L.2001, c.88 (C.26:2S-7.1 et seq.) relating to credentialing.

b. The department shall take any steps as it deems appropriate to resolve complaints and enforce the provisions of P.L.1997, c.192 (C.26:2S-1 et al.) or P.L.2001, c.88 (C.26:2S-7.1 et seq.) relating to credentialing, including, but not limited to, establishing a system to receive complaints regarding noncompliance with the provisions of P.L.1997, c.192 (C.26:2S-1 et al.) or P.L.2001, c.88 (C.26:2S-7.1 et seq.) relating to credentialing and investigating alleged violations in a timely manner.

c. Any health care professional alleging a violation of the provisions of P.L.1997, c.192 (C.26:2S-1 et al.) or P.L.2001, c.88 (C.26:2S-7.1 et seq.) relating to credentialing shall file a complaint with the department within two years of the date that the person knew or should have known of the alleged violation.

d. A carrier that violates the provisions of P.L.1997, c.192 (C.26:2S-1 et al.) or P.L.2001, c.88 (C.26:2S-7.1 et seq.) relating to credentialing shall be liable to a civil penalty, in an amount to be determined by the commissioner, which shall be collected by the commissioner in a summary proceeding before a court of competent jurisdiction pursuant to the provisions of the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.).

e. The department shall have sole and exclusive authority to enforce a violation of the provisions of P.L.1997, c.192 (C.26:2S-1 et al.) or P.L.2001, c.88 (C.26:2S-7.1 et seq.) relating to credentialing. Nothing in P.L.1997, c.192 (C.26:2S-1 et al.), P.L.2001, c.88 (C.26:2S-7.1 et seq.), or P.L. , c. (C. ) (pending before the Legislature as this bill) shall be construed as providing the basis for, or subject to, a private right of action for violations of the provisions of P.L.1997, c.192 (C.26:2S-1 et al.) or P.L.2001, c.88 (C.26:2S-7.1 et seq.) relating to credentialing.

6. This act shall take effect on the 180th day following the date of enactment.

STATEMENT

This bill makes changes to the existing health insurance carrier credentialing process to facilitate transparency and enforcement. First, the bill requires a carrier committee reviewing a credentialing application to notify the applicant within 30 days following submission of the application whether the application is incomplete. If the committee does not notify the applicant of an incomplete application within 30 days, the application is to be deemed complete. In addition, the bill requires carriers to include on their Internet websites the universal participation and renewal forms and an explanation of the credentialing process, including a list of all the documents required for participation and renewal and any expected timelines.

The bill also provides that if a physician, while waiting to receive a credential to participate in the provider network of a carrier, is delivering health care services to covered persons within the network, the carrier is required to reimburse the physician for services delivered as of the date the credentialing application was filed, if the application is approved by the carrier.

Under the bill, carriers are prohibited from requiring a physician who is already credentialed with the carrier and who changes employers or health care facilities within this State to submit a new application or renewal form to participate in the carrier's network solely on the basis that the physician changed employers or health care facilities.

Lastly, the bill authorizes the Department of Banking and Insurance to receive, investigate, and enforce alleged violations of law relating to the credentialing process.