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.