Florida Senate - 2020 SB 1684 By Senator Gruters 23-01005C-20 20201684__ 1 A bill to be entitled 2 An act relating to health care provider credentialing; 3 creating s. 456.48, F.S.; defining the term “health 4 insurer”; requiring the Financial Services Commission, 5 in consultation with the Agency for Health Care 6 Administration, to adopt a certain standard form by 7 rule for the verification of credentials of specified 8 health care professionals; requiring health insurers 9 and hospitals to use only the form to verify such 10 credentials; creating s. 456.481, F.S.; defining 11 terms; providing applicability; specifying 12 requirements for applicants to qualify for expedited 13 credentialing and for certain payments; requiring 14 managed care plans to treat applicants as 15 participating providers in their respective health 16 benefit plan networks for certain purposes; 17 authorizing a managed care plan to exclude applicants 18 from its participating provider directory or listings 19 while their applications are pending approval; 20 specifying a managed care plan’s right to recover 21 certain amounts from an applicant under certain 22 circumstances; prohibiting certain charges by an 23 applicant or the applicant’s medical group to a 24 managed care plan enrollee; providing construction; 25 creating s. 627.444, F.S.; defining the term “health 26 insurer”; specifying requirements and procedures for, 27 and restrictions on, health insurers and their 28 designees in reviewing credentialing applications; 29 authorizing a civil cause of action for applicants 30 against health insurers or designees under certain 31 circumstances; providing an effective date. 32 33 Be It Enacted by the Legislature of the State of Florida: 34 35 Section 1. Section 456.48, Florida Statutes, is created to 36 read: 37 456.48 Standardized credentialing application.— 38 (1) As used in this section, the term “health insurer” 39 means an authorized insurer offering health insurance as defined 40 in s. 624.603, a managed care plan as defined in s. 409.962, or 41 a health maintenance organization as defined in s. 641.19(12). 42 (2) The Financial Services Commission, in consultation with 43 the Agency for Health Care Administration, shall adopt by rule a 44 standardized credentialing form for verifying the credentials of 45 an applicant licensed under chapter 458, chapter 459, chapter 46 461, or chapter 466. In prescribing a form under this section, 47 the commission shall adopt the most current version of the 48 credentialing application form provided by the Council for 49 Affordable Quality Healthcare, Inc. 50 (3) Notwithstanding any other law, effective January 1, 51 2021, or 6 months after the effective date of the rule adopting 52 the standardized credentialing form, whichever is later, a 53 health insurer or a hospital licensed pursuant to chapter 395 54 shall use only the standardized credentialing form that was 55 approved by the commission to verify the credentials of an 56 applicant licensed under chapter 458, chapter 459, chapter 461, 57 or chapter 466. 58 Section 2. Section 456.481, Florida Statutes, is created to 59 read: 60 456.481 Expedited credentialing process.— 61 (1) As used in this section, the term: 62 (a) “Applicant” means a person licensed under chapter 458, 63 chapter 459, chapter 461, or chapter 466 who is applying for 64 expedited credentialing under this section. 65 (b) “Enrollee” means an individual who is eligible to 66 receive health care services under a managed care plan. 67 (c) “Managed care plan” means an insurer issuing a health 68 insurance policy pursuant to s. 627.6471 or s. 627.6472, a 69 managed care plan as defined in s. 409.962, or a health 70 maintenance organization as defined in s. 641.19(12). 71 (d) “Medical group” means an entity through which health 72 care services are provided to individuals by two or more persons 73 licensed under chapter 458, chapter 459, chapter 461, or chapter 74 466, and which receives reimbursement for such services. 75 (e) “Participating provider” means a person licensed under 76 chapter 458, chapter 459, chapter 461, or chapter 466 who has 77 contracted with a managed care plan to provide services to 78 enrollees. 79 (2) This section applies only to an applicant who joins an 80 established medical group that has a current contract in force 81 with a managed care plan. 82 (3) To qualify for expedited credentialing under this 83 section and for payment under subsection (4), an applicant must: 84 (a) Be licensed in this state by, and be in good standing 85 with, the Board of Medicine, the Board of Osteopathic Medicine, 86 the Board of Podiatric Medicine, or the Board of Dentistry, as 87 applicable; 88 (b) Submit all documentation and other information required 89 by the managed care plan as necessary to enable the managed care 90 plan to begin the credentialing process to include an applicant 91 in its health benefit plan network; and 92 (c) Agree to comply with the terms of the managed care 93 plan’s participating provider contract in force with the 94 applicant’s established medical group. 95 (4) After submission by the applicant of the information 96 required by the managed care plan, and for payment purposes 97 only, the managed care plan shall treat the applicant as if the 98 applicant were a participating provider in its health benefit 99 plan network when the applicant provides services to the managed 100 care plan’s enrollees, including: 101 (a) Authorizing the applicant to collect copayments from 102 enrollees; 103 (b) Making payments to the applicant; and 104 (c) Authorizing services provided by the applicant. 105 (5) Pending the approval of an application submitted under 106 this section, the managed care plan may exclude the applicant 107 from the managed care plan’s directory of participating 108 providers or any other listing of participating providers. 109 (6) If, on completion of the credentialing process, the 110 managed care plan determines that the applicant does not meet 111 the managed care plan’s credentialing requirements: 112 (a) The managed care plan may recover from the applicant or 113 the applicant’s medical group an amount equal to the difference 114 between payments for in-network benefits and out-of-network 115 benefits; and 116 (b) The applicant or the applicant’s medical group may 117 retain any copayments collected or in the process of being 118 collected as of the date of the managed care plan’s 119 determination. 120 (7) An enrollee in a managed care plan is not responsible, 121 and must be held harmless, for the difference between the in 122 network payment to the applicant and the out-of-network charge 123 of the applicant or the applicant’s medical group for the 124 service provided to the enrollee. The applicant and the 125 applicant’s medical group may not charge the enrollee for any 126 portion of the applicant’s fee which is not paid or reimbursed 127 by the enrollee’s managed care plan. 128 (8) A managed care plan that complies with this section is 129 not subject to liability for damages arising out of or in 130 connection with, directly or indirectly, payment by the managed 131 care plan to an applicant pursuant to subsection (4). 132 Section 3. Section 627.444, Florida Statutes, is created to 133 read: 134 627.444 Credentialing.— 135 (1) As used in this section, the term “health insurer” 136 means an authorized insurer offering health insurance as defined 137 in s. 624.603, a managed care plan as defined in s. 409.962, or 138 a health maintenance organization as defined in s. 641.19(12). 139 (2) A health insurer or its designee must provide 140 electronic or written acknowledgement to an applicant within 10 141 calendar days after the health insurer or its designee receives 142 the applicant’s application. 143 (3)(a) Upon receipt of an application, a health insurer or 144 its designee must promptly review the application to determine 145 whether it is complete. The health insurer or its designee must 146 conclude the credentialing process within 30 calendar days after 147 the date the health insurer or its designee receives a completed 148 application. 149 (b) If the health insurer or its designee determines that 150 the application is incomplete, the health insurer or its 151 designee must so notify the applicant in writing within 10 152 calendar days after the date the health insurer or its designee 153 received the application. The written notice must include a 154 detailed list of all items required to complete the application. 155 If the health insurer or its designee does not send the notice 156 within such period, the application is deemed complete. 157 (c) If the health insurer or its designee notifies the 158 applicant of an incomplete application in accordance with 159 paragraph (b), the period under paragraph (a) is tolled and the 160 application is suspended from the date on which the notice was 161 sent to the applicant until the date on which the health insurer 162 or its designee receives the required information from the 163 applicant. 164 (d) The health insurer or its designee may request only 165 that information necessary for the health insurer or its 166 designee to fairly and responsibly evaluate the application. 167 (4) An applicant may bring an action in a court of 168 appropriate jurisdiction against a health insurer or its 169 designee for a violation of this section. 170 Section 4. This act shall take effect July 1, 2020.