(a) An insurer or MA or CHIP managed care plan shall establish a credentialing process to enroll qualified health care providers and create an adequate provider network.

(a.1) An insurer's or MA or CHIP managed care plan's credentialing process shall be subject to approval by the department and shall include written criteria and procedures for at least the following:

(b) The department shall establish credentialing standards for insurers and MA or CHIP managed care plans. The department may adopt nationally recognized accrediting standards to establish the credentialing standards for insurers and MA or CHIP managed care plans.

(c) An insurer or MA or CHIP managed care plan shall submit a report to the department regarding its credentialing process at least every two (2) years or as may otherwise be required by the department.

(d) An insurer or MA or CHIP managed care plan shall disclose relevant credentialing criteria and procedures to health care providers that apply to participate or that are participating in the insurer's or MA or CHIP managed care plan's provider network. An insurer or MA or CHIP managed care plan shall also disclose relevant credentialing criteria and procedures pursuant to a court order or rule. Any individual providing information during the credentialing process of an insurer or MA or CHIP managed care plan shall have the protections set forth in the act of July 20, 1974 (P.L. 564, No. 193),¹ known as the “Peer Review Protection Act.”

(e) No insurer or MA or CHIP managed care plan may exclude or terminate a health care provider from participation in the insurer's or MA or CHIP managed care plan's provider network due to any of the following:

(f) If an insurer or MA or CHIP managed care plan denies enrollment or renewal of credentials to a health care provider, the insurer or MA or CHIP managed care plan shall provide the health care provider with written notice of the decision. The notice shall include a clear rationale for the decision.