Read the full stored bill text
House
File
556
-
Introduced
HOUSE
FILE
556
BY
A.
MEYER
A
BILL
FOR
An
Act
relating
to
health
insurers’
credentialing
process.
1
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
2
TLSB
1798YH
(2)
91
nls/ko
H.F.
556
Section
1.
Section
514F.6,
Code
2025,
is
amended
to
read
as
1
follows:
2
514F.6
Credentialing
——
retrospective
payment
.
3
1.
Retrospective
payment.
The
commissioner
shall
adopt
4
rules
to
provide
for
the
retrospective
payment
of
clean
5
claims
for
covered
services
provided
by
a
physician,
advanced
6
registered
nurse
practitioner,
or
physician
assistant
during
7
the
credentialing
period,
once
the
physician,
advanced
8
registered
nurse
practitioner,
or
physician
assistant
is
9
credentialed.
10
2.
Credentialing
process.
11
a.
A
health
insurer
shall
respond
to
a
physician,
advanced
12
registered
nurse
practitioner,
or
physician
assistant’s
request
13
for
credentialing
within
fifty-six
calendar
days
from
the
date
14
of
the
request.
15
b.
If
a
physician’s,
advanced
registered
nurse
16
practitioner’s,
or
physician
assistant’s
request
for
17
credentialing
is
denied
by
the
health
insurer,
the
health
18
insurer
shall
provide
a
reason
for
the
denial,
in
writing,
19
to
the
physician,
advanced
registered
nurse
practitioner,
or
20
physician
assistant.
21
c.
A
physician,
advanced
registered
nurse
practitioner,
or
22
physician
assistant
who
is
denied
credentialing
shall
have
an
23
opportunity,
after
an
internal
appeal,
to
appeal
the
denial
24
to
the
insurance
division.
In
addition
to
any
other
grounds
25
for
an
appeal,
network
adequacy
shall
constitute
grounds
for
a
26
physician,
advanced
nurse
practitioner,
or
physician
assistant
27
to
appeal.
28
2.
3.
Definitions.
For
purposes
of
this
section
:
29
a.
“Advanced
registered
nurse
practitioner”
means
a
person
30
currently
licensed
as
a
registered
nurse
under
chapter
152
or
31
152E
who
is
licensed
by
the
board
of
nursing
as
an
advanced
32
registered
nurse
practitioner.
33
b.
“Clean
claim”
means
the
same
as
defined
in
section
34
507B.4A,
subsection
2
,
paragraph
“b”
.
35
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H.F.
556
c.
“Credentialing”
means
a
process
through
which
a
health
1
insurer
makes
a
determination
based
on
criteria
established
by
2
the
health
insurer
concerning
whether
a
physician,
advanced
3
registered
nurse
practitioner,
or
physician
assistant
is
4
eligible
to
provide
health
care
services
to
an
insured
and
to
5
receive
reimbursement
for
the
health
care
services
provided
6
under
an
agreement
entered
into
between
the
physician,
advanced
7
registered
nurse
practitioner,
or
physician
assistant
and
the
8
health
insurer.
9
d.
“Credentialing
period”
means
the
time
period
between
the
10
health
insurer’s
receipt
of
a
physician’s,
advanced
registered
11
nurse
practitioner’s,
or
physician
assistant’s
application
for
12
credentialing
and
approval
of
that
application
by
the
health
13
insurer.
14
e.
“Physician”
means
a
licensed
doctor
of
medicine
and
15
surgery
or
a
licensed
doctor
of
osteopathic
medicine
and
16
surgery.
17
f.
“Physician
assistant”
means
a
person
who
is
licensed
to
18
practice
as
a
physician
assistant
under
the
supervision
of
one
19
or
more
physicians.
20
EXPLANATION
21
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
22
the
explanation’s
substance
by
the
members
of
the
general
assembly.
23
This
bill
relates
to
health
insurers’
credentialing
process.
24
Under
the
bill,
a
health
insurer
(insurer)
shall
respond
25
to
a
physician,
advanced
registered
nurse
practitioner,
or
26
physician
assistant’s
request
for
credentialing
within
56
27
calendar
days.
If
a
request
for
credentialing
is
denied
by
28
the
insurer,
the
insurer
shall
provide
a
reason
for
the
denial
29
to
the
physician,
advanced
registered
nurse
practitioner,
or
30
physician
assistant.
The
physician,
advanced
registered
nurse
31
practitioner,
or
physician
assistant
shall
have
an
opportunity,
32
after
an
internal
appeal,
to
appeal
the
denial
to
the
insurance
33
division.
In
addition
to
any
other
grounds
for
an
appeal,
34
network
adequacy
shall
constitute
grounds
for
an
appeal.
35
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