health insurers; provisional provider credentialing

Plain English Breakdown

The effective date is not listed in the official text, though applicability begins for applications submitted on or after December 31, 2026.

SB1228: Rules for Temporary Provider Approval by Health Insurers

This law requires health insurers to temporarily approve certain new providers and pay their claims at contracted rates while waiting for a final decision on full approval.

What This Bill Does

• Requires health insurers to grant provisional credentialing when a provider meets specific conditions, including being licensed in good standing and credentialed by an approved organization or institution.
• Mandates that insurers pay claims at the rates established in the contract between the insurer and the group practice or health care institution during the temporary approval period.
• Sets a limit of sixty days after application submission, or until final approval or denial, for how long provisional status lasts.
• States that if an application is denied, insurers are not responsible for services provided after the denial date and cannot recover money paid unless fraud occurred.

Who It Names or Affects

• Health insurers operating in Arizona
• Medical providers applying to join a network who meet specific licensing and credentialing requirements
• Group practices or health care institutions that have existing contracts with health insurers

Terms To Know

Provisional credentialing

Temporary approval for a provider starting when the insurer receives a complete application, lasting until final decision or sixty days.

Credentialing verification organization

An entity that verifies if a medical provider has the right licenses and training as required by this law.

Limits and Unknowns

• The law only applies to applications submitted on or after December 31, 2026.
• Insurers do not have to pay for services given after they deny an application.
• The official text does not state the exact date this bill becomes effective.

Official Summary Text

SB1228 - health insurers; provisional provider credentialing

Current Bill Text

SB1228 - 572R - I Ver

REFERENCE TITLE:
health insurers; provisional provider credentialing

State of Arizona

Senate

Fifty-seventh Legislature

Second Regular Session

2026

SB 1228

Introduced by

Senator
Fernandez

AN
ACT

amending title 20, chapter 27, article 1,
arizona revised statutes, by adding section 20-3460; relating to provider
credentialing.

(TEXT OF BILL BEGINS ON NEXT PAGE)

Be it enacted by the Legislature of the State of Arizona:

Section 1. Title 20, chapter 27, article 1,
Arizona Revised Statutes, is amended by adding section 20-3460, to read:

START_STATUTE
20-3460.

Provisional credentialing; reimbursement requirements; definition

A. A health insurer shall grant
provisional credentialing to a provider that begins on the date the health
insurer receives a complete credentialing application from the provider, if the
provider:

1. Is licensed in this state and in
good standing.

2. Has been credentialed by a
licensed health care institution's medical staff office or a credentialing
verification organization.

3. Has joined a group practice or
health care institution that has an existing contract with a health insurer.

B. During the provisional
credentialing period, a health insurer shall pay all claims that are submitted
by the provider at the rates established in the contract between the health
insurer and the group practice or health care institution.

C. Provisional credentialing remains
in effect until the earlier of either:

1. The health insurer's approval or
denial of the provider's complete credentialing application.

2. Sixty days after the date the
complete credentialing application was submitted.

D. If a health insurer denies a
complete credentialing application, the health insurer is not responsible for
reimbursing claims for services that were provided after the date of the denial
and may not recover monies paid for claims that were submitted during the
provisional credentialing period unless the claims were fraudulent.

E. For the purposes of this section,
"Health care institution" has the same meaning prescribed in section
36-401.
END_STATUTE

Sec. 2.
Applicability

This act applies to credentialing
applications that are submitted beginning from and after December 31, 2026.