Sec. 7. (a) This section applies to an insurer that issues or administers a policy that provides coverage for basic health care services (as defined in IC 27-13-1-4).

(b) The department of insurance shall prescribe the credentialing application form used by the Council for Affordable Quality Healthcare (CAQH) in electronic or paper format, which must be used by:

(1) a provider who applies for credentialing by an insurer; and

(2) an insurer that performs credentialing activities.

(c) An insurer shall notify a provider concerning a deficiency on a completed credentialing application form submitted by the provider not later than thirty (30) business days after the insurer receives the completed credentialing application form.

(d) An insurer shall notify a provider concerning the status of the provider's completed credentialing application not later than:

(1) sixty (60) days after the insurer receives the completed credentialing application form; and

(2) every thirty (30) days after the notice is provided under subdivision (1), until the insurer makes a final credentialing determination concerning the provider.

(e) Notwithstanding subsection (d), if an insurer fails to issue a credentialing determination within thirty (30) days after receiving a completed credentialing application form from a provider, the insurer shall provisionally credential the provider if the provider meets the following criteria:

(1) The provider has submitted a completed and signed credentialing application form and any required supporting material to the insurer.

(2) The provider was previously credentialed by the insurer in Indiana and in the same scope of practice for which the provider has applied for provisional credentialing.

(3) The provider is a member of a provider group that is credentialed and a participating provider with the insurer.

(4) The provider is a network provider with the insurer.

(f) The criteria for issuing provisional credentialing under subsection (e) may not be less stringent than the standards and guidelines governing provisional credentialing from the National Committee for Quality Assurance or its successor organization.

(g) Once an insurer fully credentials a provider that holds provisional credentialing, reimbursement payments under the contract shall be retroactive to the date of the provisional credentialing. The insurer shall reimburse the provider at the rates determined by the contract between the provider and the insurer.

(h) If an insurer does not fully credential a provider that is provisionally credentialed under subsection (e), the provisional credentialing is terminated on the date the insurer notifies the provider of the adverse credentialing determination. The insurer is not required to reimburse for services rendered while the provider was provisionally credentialed.

As added by P.L.26-2005, SEC.2. Amended by P.L.195-2018, SEC.18.