Health care coverage: health care provider credentials.

Plain English Breakdown

The bill summary does not provide specific details on what happens if provisional approval cannot be given after 90 days and certain conditions apply.

Health Care Provider Credentials

AB-1041 requires health care service plans and insurers to use specific credentialing forms starting January 1, 2028, and sets a 90-day limit for verifying provider qualifications.

What This Bill Does

• Requires every full-service health care plan or insurer to subscribe to and use the Council for Affordable Quality Healthcare's credentialing form on and after January 1, 2028.
• Sets a 90-day limit for health care service plans or insurers to verify and approve new providers' credentials after receiving an application.
• Allows provisional approval of provider credentials if verification takes longer than 90 days but not more than 120 days unless certain conditions apply, such as disciplinary action against the provider.
• Requires notifying applicants when their credentials are approved and activating them in the network.

Who It Names or Affects

• Health care service plans
• Health insurers
• Health care providers applying for network inclusion

Terms To Know

Credentialing form

A document used to verify the qualifications and credentials of health care providers.

Provisional approval

Temporary acceptance of a provider's application while verification is ongoing, subject to certain conditions.

Limits and Unknowns

• The bill does not specify what happens if the 90-day requirement is not met and provisional approval cannot be given.
• It excludes Medi-Cal managed care plans from these provisions.

Official Summary Text

AB 1041, Bennett.
Health care coverage: health care provider credentials.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act’s requirements a crime. Existing law provides for the regulation of disability and health insurers by the Department of Insurance.
This bill would require every full service health care service plan or health insurer, or its delegate, to subscribe to and use the Council for Affordable Quality Healthcare credentialing form on and after January 1, 2028, except as specified.
Existing law requires a health care service plan or disability insurer that provides coverage for mental health and substance use disorders and that credentials health care providers of those services for its networks to assess and verify the qualifications of a health care
provider within 60 days after receiving a completed provider credentialing application.
This bill would, except as provided above and within one year of the bill’s operative date, require every health care service plan or health insurer, or its delegate, that credentials health care providers for
its networks to make a determination regarding the credentials of a provider within 90 days after receiving a completed provider credentialing application. The bill would require every health care service plan or health insurer to activate the provider upon successful approval and notify the applicant of the activation, as specified. If the health care service plan or health insurer, or its delegate, does not meet the 90-day requirement, the bill would require the applicant’s credentials to be provisionally approved for 120 days unless specified circumstances apply, including that the applicant is subject to discipline by the licensing entity for that
applicant. The bill would exclude Medi-Cal managed care plans from these provisions.
Because a willful violation of these provisions by a health care service plan would be a crime, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.

Current Bill Text

Download Bill PDF