Florida Senate - 2025 SB 1236
By Senator Simon
3-01785-25 20251236__
1 A bill to be entitled
2 An act relating to centralized Medicaid provider
3 credentialing; creating s. 409.9073, F.S.; defining
4 terms; requiring Medicaid managed care organizations
5 operating in this state on or after a specified date
6 to require their providers to comply with specified
7 accreditation requirements; specifying procedures for
8 provider enrollment; requiring the Agency for Health
9 Care Administration to enroll providers within a
10 specified timeframe after receiving a clean
11 application; providing for tolling of such timeframe
12 under certain circumstances; requiring credentialing
13 verification organizations to implement a single
14 credentialing application through a web-based portal;
15 specifying requirements and procedures for provider
16 credentialing; specifying provisions that apply if the
17 agency designates a single credentialing verification
18 organization for provider credentialing; requiring
19 Medicaid managed care organizations to make a
20 determination within a specified timeframe after
21 receiving verified credentialing information;
22 requiring Medicaid managed care organizations to
23 ensure that internal processing systems of the
24 organization are updated within a specified timeframe
25 after a contract with a provider is executed;
26 providing construction; providing that once approved
27 for enrollment, a provider’s claims become eligible
28 for payment on the date on which the provider’s
29 credentialing application was approved; prohibiting
30 Medicaid managed care organizations from requiring
31 providers to appeal or resubmit clean claims submitted
32 during a specified period; providing applicability;
33 encouraging relevant provider licensing boards to
34 forward and provide certain information electronically
35 to the agency and credentialing verification
36 organizations; authorizing the agency to adopt rules;
37 providing an effective date.
38
39 Be It Enacted by the Legislature of the State of Florida:
40
41 Section 1. Section 409.9073, Florida Statutes, is created
42 to read:
43 409.9073 Medicaid provider credentialing.—
44 (1) As used in this section, the term:
45 (a) “Clean application” means:
46 1. For credentialing purposes, a credentialing application
47 submitted by a provider to a credentialing verification
48 organization which:
49 a. Is complete and correct;
50 b. Does not lack any required substantiating documentation;
51 and
52 c. Is consistent with the requirements set by the National
53 Committee for Quality Assurance; or
54 2. For enrollment purposes, an enrollment application
55 submitted by a provider to the agency which:
56 a. Is complete and correct;
57 b. Does not lack any required substantiating documentation;
58 c. Complies with all provider screening requirements of 42
59 C.F.R. part 455; and
60 d. Is submitted on behalf of a provider who does not have
61 accounts receivable with the agency.
62 (b) “Credentialing application date” means the date on
63 which a credentialing verification organization or the agency
64 receives a clean application from a provider.
65 (c) “Credentialing verification organization” means an
66 organization that gathers data and verifies the credentials of
67 providers in a manner consistent with federal and state laws and
68 the requirements of the National Committee for Quality
69 Assurance.
70 (d) “Managed care organization” means an entity with which
71 the agency has contracted to serve as a managed care
72 organization as defined in 42 C.F.R. s. 438.2 under the Medicaid
73 program.
74 (2) A managed care organization operating in this state on
75 or after July 1, 2025, for the delivery of Medicaid services
76 shall require its providers to comply with the accrediting
77 requirements of this section.
78 (3) The agency shall enroll a provider within 60 calendar
79 days after receipt of a clean application for provider
80 enrollment. The credentialing application date is considered the
81 date of enrollment. The time limits established in this section
82 must be tolled or paused for any delay caused by an external
83 entity. Tolling events include, but are not limited to, the
84 screening requirements contained in 42 C.F.R. part 455 and
85 searches of federal databases maintained by entities such as the
86 Centers for Medicare and Medicaid Services.
87 (4) A credentialing verification organization established
88 under this section shall do all of the following:
89 (a) Implement a single credentialing application through a
90 web-based portal available to all providers seeking to be
91 credentialed for any Medicaid managed care organization.
92 (b) Perform primary source verification and credentialing
93 committee review of each credentialing application that results
94 in a recommendation on the provider’s credentialing within 30
95 days after receipt of a clean application.
96 (c) Notify providers within 5 business days after receipt
97 of a credentialing application if the application is incomplete.
98 (d) Provide provider outreach and help desk services during
99 common business hours to facilitate provider applications and
100 credentialing information.
101 (e) Expeditiously communicate the credentialing
102 recommendation and supporting credentialing information
103 electronically to the agency and to each participating Medicaid
104 managed care organization with which the provider is seeking
105 credentialing.
106 (f) Conduct reevaluation of provider documentation when
107 required by state or federal law or when necessary for the
108 provider to maintain participation status with a Medicaid
109 managed care organization.
110 (5) If the agency designates a single credentialing
111 verification organization under this section, all of the
112 following provisions apply:
113 (a) The contract between the agency and the credentialing
114 verification organization must be submitted to the Department of
115 Management Services for comment and review.
116 (b) The credentialing verification organization must be
117 reimbursed on a per provider credentialing basis by the agency
118 with the reimbursement being offset or deducted equally from
119 each managed care organizations capitation payment.
120 (c) The credentialing verification organization must comply
121 with paragraph (6)(b).
122 (d) The agency must adopt rules necessary to ensure the
123 timely and efficient credentialing of providers.
124 (6) A Medicaid managed care organization shall do all of
125 the following:
126 (a) Make a determination within 30 calendar days after it
127 receives verified credentialing information for a provider from
128 a credentialing verification organization designated by the
129 agency.
130 (b) Within 10 days after it executes a contract with a
131 provider, ensure that any internal processing systems of the
132 managed care organization have been updated to include:
133 1. The accepted provider contract; and
134 2. The provider as a participating provider.
135 (7)(a) This section does not require a Medicaid managed
136 care organization to contract with a provider if the managed
137 care organization and the provider do not agree on the terms and
138 conditions for participation.
139 (b) This section does not prohibit a provider and a managed
140 care organization from negotiating the terms of a contract
141 before completion of the agency’s enrollment and screening
142 process.
143 (8)(a) For the purpose of reimbursement of claims, once a
144 provider has met the terms and conditions for credentialing and
145 enrollment, the provider’s claims become eligible for payment
146 beginning on the date the provider’s credentialing application
147 was approved.
148 (b) A Medicaid managed care organization may not require a
149 provider to appeal or resubmit any clean claim submitted during
150 the time period between the provider’s credentialing application
151 date and the completion of the credentialing process.
152 (c) This subsection does not limit the agency’s authority
153 to establish the criteria that will allow a provider’s claims to
154 become eligible for payment in the event of lifesaving or life
155 preserving medical treatment, including, but not limited to, an
156 organ transplant.
157 (9) This section does not prohibit a teaching hospital as
158 defined in s. 408.07 from performing the activities of a
159 credentialing verification organization for its employed
160 physicians, residents, and mid-level practitioners when such
161 activities are delineated in the hospital’s contract with a
162 Medicaid managed care organization. The provisions of this
163 section relating to reimbursements and timely action on a
164 credentialing application apply to a credentialing application
165 that has been verified through a teaching hospital under this
166 subsection.
167 (10) To promote seamless integration of licensure
168 information, the relevant provider licensing boards in this
169 state are encouraged to forward and provide licensure
170 information electronically to the agency and any credentialing
171 verification organization.
172 (11) The agency may adopt rules to implement this section.
173 Section 2. This act shall take effect July 1, 2025.