1| HOUSE OF REPRESENTATIVES - FLOOR VERSION |
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2| STATE OF OKLAHOMA |
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3| 2nd Session of the 59th Legislature (2024) |
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4|ENGROSSED SENATE |
|BILL NO. 1631 By: Coleman of the Senate |
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| Tedford of the House |
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9| An Act relating to insurance; amending 36 O.S. 2021, |
| Section 4405.1, which relates to credentialing or |
10| recredentialing of health care providers; requiring |
| certain notice following credential application |
11| determination; updating statutory language; updating |
| statutory reference; and providing an effective date. |
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14|BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: |
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15| SECTION 1. AMENDATORY 36 O.S. 2021, Section 4405.1, is |
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16|amended to read as follows: |
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17| Section 4405.1. A. As used in this section: |
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18| 1. a. "Health benefit plan" or "plan" means: |
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19| (1) group hospital or medical insurance coverages, |
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20| (2) not-for-profit hospital or medical service or |
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21| indemnity plans, |
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22| (3) prepaid health plans, |
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23| (4) health maintenance organizations, |
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24| (5) preferred provider plans, |
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1| (6) Multiple Employer Welfare Arrangements multiple |
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2| employer welfare arrangements (MEWA), or |
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3| (7) employer self-insured plans that are not exempt |
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4| pursuant to the federal Employee Retirement |
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5| Income Security Act of 1974 (ERISA) provisions, |
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6| and |
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7| b. the term "health benefit plan" health benefit plan |
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8| shall not include: |
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9| (1) individual plans, |
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10| (2) plans that only provide coverage for a specified |
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11| disease, accidental death, or dismemberment for |
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12| wages or payments in lieu of wages for a period |
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13| during which an employee is absent from work |
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14| because of sickness or injury or as a supplement |
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15| to liability insurance, |
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16| (3) Medicare supplemental policies as defined in |
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17| Section 1882(g)(1) of the federal Social Security |
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18| Act (42 U.S.C., Section 1395ss), |
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19| (4) workers' compensation insurance coverage, |
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20| (5) medical payment insurance issued as a part of a |
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21| motor vehicle insurance policy, or |
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22| (6) long-term care policies, including nursing home |
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23| fixed indemnity policies, unless the Insurance |
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24| Commissioner determines that the policy provides |
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1| comprehensive benefit coverage sufficient to meet |
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2| the definition of a health benefit plan; and |
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3| 2. "Credentialing" or "recredentialing", as applied to |
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4|physicians and other health care providers, means the process of |
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5|accessing and validating the qualifications of such persons to |
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6|provide health care services to the beneficiaries of a health |
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7|benefit plan. Credentialing or recredentialing may include, but is |
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8|not limited to, an evaluation of licensure status, education, |
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9|training, experience, competence and professional judgment. |
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10| Credentialing or recredentialing is a prerequisite to the final |
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11|decision of a health benefit plan to permit initial or continued |
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12|participation by a physician or other health care provider. |
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13| B. 1. Any health benefit plan that is offered, issued or |
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14|renewed in this state shall provide for credentialing and |
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15|recredentialing of physicians and other health care providers based |
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16|on criteria provided in the uniform credentialing application |
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17|required by Section 1-106.2 of Title 63 of the Oklahoma Statutes. |
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18| 2. Health benefit plans shall make information on such criteria |
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19|available to physician and other health care provider applicants, |
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20|participating physicians, and other participating health care |
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21|providers and shall provide applicants with a checklist of materials |
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22|required in the application process. |
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23| 3. Physicians or other health care providers under |
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24|consideration to provide health care services under a health benefit |
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1|plan in this state shall apply for credentialing or recredentialing |
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2|on the uniform credentialing application and shall provide the |
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3|documentation as outlined in the plan's checklist of materials |
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4|required in the application process. |
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5| C. A health benefit plan shall determine whether a |
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6|credentialing or recredentialing application is complete. If an |
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7|application is determined to be incomplete, the plan shall notify |
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8|the applicant in writing within ten (10) calendar days of receipt of |
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9|the application. The written notice shall specify the portion of |
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10|the application that is causing a delay in processing and explain |
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11|any additional information or corrections needed. |
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12| D. 1. In reviewing the application, the health benefit plan |
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13|shall evaluate each application according to the plan's checklist of |
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14|required materials that accompanies the application. |
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15| 2. When an application is deemed complete, the plan shall |
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16|initiate requests for primary source verification and malpractice |
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17|history within seven (7) calendar days. |
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18| 3. A malpractice carrier shall have twenty-one (21) calendar |
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19|days within which to respond after receipt of an inquiry from a |
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20|health benefit plan. Any malpractice carrier that fails to respond |
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21|to an inquiry within the time frame may be assessed an |
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22|administrative penalty by the Insurance Commissioner. |
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23| E. 1. Upon receipt of primary source verification and |
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24|malpractice history by the plan, the plan shall determine if the |
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1|application is a clean application. If the application is deemed |
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2|clean, a plan shall have forty-five (45) calendar days within which |
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3|to credential or recredential a physician or other health care |
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4|provider. As used in this paragraph, "clean application" means an |
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5|application that has no defect, misstatement of facts, |
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6|improprieties, including a lack of any required substantiating |
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7|documentation, or particular circumstance requiring special |
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8|treatment that impedes prompt credentialing or recredentialing. |
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9| 2. If a plan is unable to credential or recredential a |
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10|physician or other health care provider due to an application's |
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11|application not being clean, the plan may extend the credentialing |
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12|or recredentialing process for sixty (60) calendar days. At the end |
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13|of sixty (60) calendar days, if the plan is awaiting documentation |
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14|to complete the application, the physician or other health care |
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15|provider shall be notified of the reason for the delay by certified |
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16|mail. The physician or other health care provider may extend the |
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17|sixty-day period upon written notice to the plan within ten (10) |
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18|calendar days; otherwise the application shall be deemed withdrawn. |
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19|In no event shall the entire credentialing or recredentialing |
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20|process exceed one hundred eighty (180) calendar days. |
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21| 3. If an application for credentialing or recredentialing is |
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22|denied, the plan shall notify the applicant in writing the reason |
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23|for the denial and what corrective actions the applicant may |
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1|consider within ten (10) calendar days of the determination to deny |
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2|the application. |
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3| 4. A health benefit plan shall be prohibited from solely basing |
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4|a denial of an application for credentialing or recredentialing on |
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5|the lack of board certification or board eligibility and from adding |
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6|new requirements solely for the purpose of delaying an application. |
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7| 4. 5. Any health benefit plan that violates the provisions of |
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8|this section may be assessed an administrative penalty by the |
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9|Commissioner. |
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10| F. Within thirty-one (31) days after a provider has been |
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11|credentialed by a health benefit plan following the completion of |
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12|the credentialing or recredentialing process pursuant to this |
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13|section, the health benefit plan shall consider the provider |
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14|in-network for purposes of reimbursement. |
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15| SECTION 2. This act shall become effective November 1, 2024. |
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17|COMMITTEE REPORT BY: COMMITTEE ON RULES, dated 04/09/2024 - DO PASS. |
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