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.