SECTION 1. Section 1 of Chapter 176O of the General Laws is hereby amended by
inserting after the definition of “Covered benefits” the following new definition:—
“ Credentialing” means the process of assessing and validating the qualifications of health care providers applying to be approved or reapproved by a health insurance carrier to provide health care services to the health insurance carrier’s insured. The process shall not allow any economic criteria to be used in determining an individual’s qualifications.
SECTION 2. Said section 1 of Chapter 176O is hereby further amended by inserting after the definition of "health care services" the following new definition:—
"Hospital-based physician", a pathologist, anesthesiologist, radiologist or emergency room physician who practices exclusively within the inpatient or outpatient hospital setting and who provides health care services to a carrier's insured only as a result of insured being directed to the hospital inpatient or outpatient setting. This definition may be expanded, by the division of insurance upon consultation with the Massachusetts Hospital Association, Massachusetts Medical Society, Massachusetts Association of Health Plans and Blue Cross and Blue Shield of Massachusetts, by regulation to include additional categories of physicians who practice exclusively within the inpatient or outpatient hospital setting and who provide health care services to a carrier's insured only as a result of insured being directed to the hospital inpatient or outpatient setting.
SECTION 3. Chapter 176O of the General Laws as appearing in the 2004 official edition is hereby amended by inserting after section 2 the following new sections:—
Section 2A. (a) The bureau shall adopt the "Integrated Massachusetts Application for Initial Credentialing/Appointment" and the "Integrated Massachusetts Application for Re-Credentialing/Re-Appointment," so called, and any revisions thereto, as developed and updated from time to time by the Massachusetts Medical Society, the Massachusetts Hospital Association, the Massachusetts Association of Health Plans and Blue Cross Blue Shield of Massachusetts as the statewide uniform physician credentialing application forms. Such forms shall not be applicable in those instances where the carrier has both delegated credentialing to a provider organization and does not require submission of a credentialing application.
(b) A carrier shall not use any initial physician credentialing application form other than the uniform initial physician application form or a uniform electronic version of said form. A carrier shall not use any physician recredentialing application form other than the uniform physician recredentialing application form or a uniform electronic version of said form.
A carrier may require that the appropriate physician profile be submitted in addition to the uniform physician recedentialing application form.
(c) A carrier shall act upon and complete the credentialing process for
95% of complete initial physician credentialing applications submitted by or on behalf of a physician applicant within 30 calendar days of receipt of a complete application. An application shall be considered complete if it contains all of the following elements:
1. the application form is signed and appropriately dated by the physician applicant;
2. all information on the application is submitted in a legible and complete manner and any affirmative answers are accompanied by explanations satisfactory to the carrier;
3. a current curriculum vitae with appropriate required dates;
4. a signed, currently dated Applicant's Authorization to Release Information form;
5. copies of the applicant's current licenses in all states in which the physician practices;
6. a copy of the applicant's current Massachusetts controlled substances registration and a copy of the applicant's current federal DEA controlled substance certificate or, if not available, a letter describing prescribing arrangements;
7. a copy of the applicant's current malpractice fact sheet coverage statement including amounts and dates of coverage;
8. hospital letter or verification of hospital privileges or alternate pathways;
9. documentation of board certification or alternate pathways;
10. documentation of training, if not board certified;
11. there are no affirmative responses on questions related to quality or clinical competence;
12. there are no modifications to the Applicant's Authorization to Release Information Form;
13. there are no discrepancies between the information submitted by or on behalf of the physician and information received from other sources; and
14. the appropriate health plan participation agreement, if applicable.
(d) A carrier shall report to a physician applicant or designee the status of a submitted initial credentialing application within a reasonable timeframe. Said report shall include, but not be limited to, the application receipt date and, if incomplete, an itemization of all missing or incomplete items. A carrier may return an incomplete application to the submitter. A physician applicant or designee shall be responsible for any and all missing or incomplete items.
(e) A carrier shall notify a physician applicant of the carrier's credentialing committee's decision on an initial credentialing application within four business days of the decision. Said notice shall include the committee's decision and the decision date.
(f) A physician, other than a primary care provider compensated on a capitated basis, who has been credentialed pursuant to the terms of this section shall be allowed to treat a carrier's insured and shall be reimbursed by the carrier for covered services provided to a carrier's insured effective as of the carrier's credentialing committee's decision date. A primary care physician compensated on a capitated basis who has been credentialed pursuant to the terms established in this section shall be allowed to treat a carrier's insured and shall be reimbursed by the carrier for covered services provided to the carrier's insured effective no later than the first day of the month following the carrier's credentialing committee's decision date.
(g) The provisions of this section shall not apply to the credentialing and recredentialing by carriers of psychiatrists or hospital-based physicians by carriers.
Section 2B. (a) The bureau's accreditation requirements related to credentialing and recredentialing shall not require a carrier to complete the credentialing or recredentialing process for hospital-based physicians.
(b) Except as provided in paragraph (d), a carrier shall not require a hospital-based physician to complete the credentialing and recredentialing process established pursuant to the bureau's accreditation requirements.
(c) A carrier may establish an abbreviated data submission process for hospital-based physicians. Except as provided in paragraph (d) of this section, said process shall be limited to a review of the data elements required to be collected and reviewed pursuant to applicable regulations of the board of registration in medicine and shall not include primary source verification or a carrier's credentialing committee review.
(d) In the event that the carrier determines that there is a need to further review a hospital-based physicians credentials due to quality of care concerns, complaints from insured, applicable law or other good faith concerns, the carrier may conduct such review as is necessary to make a credentialing or recredentialing decision.
(e) Nothing in this section shall be construed to prohibit a carrier from requiring a physician to submit information or taking other actions necessary for the carrier to comply with the applicable regulations of the board of registration in medicine.
(f) The Massachusetts Hospital Association, the Massachusetts Medical Society, the Massachusetts Association of Health Plans and Blue Cross and Blue Shield of Massachusetts shall work to develop standard criteria and oversight guidelines that may be used by carriers to delegate the credentialing function to providers. Such criteria and oversight guidelines shall meet applicable accreditation standards.
(g) Notwithstanding any special or general law to the contrary, nothing in section 2A or 2B shall be construed as an exemption to federal or state antitrust laws, or as authorizing carriers, physicians or hospitals to engage in discrimination of health care providers; in relation to completing credentialing or recredentialing application forms or satisfying credentialing requirements of carriers, or of those providers the bureau has delegated credentialing functions to.
SECTION 4. Sections 2A(a) and 2A(b) in Section 2 shall take effect January 1, 2015.
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