§ 4405.1. Health benefit plans--Credentialing or recredentialing of physicians and other health...
Oklahoma Statutes AnnotatedTitle 36. Insurance
36 Okl.St.Ann. § 4405.1
§ 4405.1. Health benefit plans--Credentialing or recredentialing of physicians and other health care providers
(7) employer self-insured plans that are not exempt pursuant to the federal Employee Retirement Income Security Act (ERISA)1 provisions, and
2. “Credentialing” or “recredentialing”, as applied to physicians and other health care providers, means the process of accessing and validating the qualifications of such persons to provide health care services to the beneficiaries of a health benefit plan. Credentialing or recredentialing may include, but is not limited to, an evaluation of licensure status, education, training, experience, competence and professional judgment.
Credentialing or recredentialing is a prerequisite to the final decision of a health benefit plan to permit initial or continued participation by a physician or other health care provider.
B. 1. Any health benefit plan that is offered, issued or renewed in this state shall provide for credentialing and recredentialing of physicians and other health care providers based on criteria provided in the uniform credentialing application required by Section 1-106.2 of Title 63 of the Oklahoma Statutes.
3. Physicians or other health care providers under consideration to provide health care services under a health benefit plan in this state shall apply for credentialing or recredentialing on the uniform credentialing application and shall provide the documentation as outlined in the plan's checklist of materials required in the application process.
C. A health benefit plan shall determine whether a credentialing or recredentialing application is complete. If an application is determined to be incomplete, the plan shall notify the applicant in writing within ten (10) calendar days of receipt of the application. The written notice shall specify the portion of the application that is causing a delay in processing and explain any additional information or corrections needed.
3. A malpractice carrier shall have twenty-one (21) calendar days within which to respond after receipt of an inquiry from a health benefit plan. Any malpractice carrier that fails to respond to an inquiry within the time frame may be assessed an administrative penalty by the Insurance Commissioner.
E. 1. Upon receipt of primary source verification and malpractice history by the plan, the plan shall determine if the application is a clean application. If the application is deemed clean, a plan shall have forty-five (45) calendar days within which to credential or recredential a physician or other health care provider. As used in this paragraph, “clean application” means an application that has no defect, misstatement of facts, improprieties, including a lack of any required substantiating documentation, or particular circumstance requiring special treatment that impedes prompt credentialing or recredentialing.
2. If a plan is unable to credential or recredential a physician or other health care provider due to an application's not being clean, the plan may extend the credentialing or recredentialing process for sixty (60) calendar days. At the end of sixty (60) calendar days, if the plan is awaiting documentation to complete the application, the physician or other health care provider shall be notified of the reason for the delay by certified mail. The physician or other health care provider may extend the sixty-day period upon written notice to the plan within ten (10) calendar days; otherwise the application shall be deemed withdrawn. In no event shall the entire credentialing or recredentialing process exceed one hundred eighty (180) calendar days.
Credits
Laws 2001, c. 273, § 1, eff. Nov. 1, 2001; Laws 2002, c. 156, § 1, eff. Nov. 1, 2002; Laws 2015, c. 376, § 1, eff. Nov. 1, 2015.
Footnotes
29 U.S.C.A. § 1001 et seq.
36 Okl. St. Ann. § 4405.1, OK ST T. 36 § 4405.1
Current with emergency effective legislation through Chapter 182 of the Second Regular Session of the 59th Legislature (2024). Some sections may be more current, see credits for details.
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