AN ACT RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES -- HEALTHCARE PROVIDER CREDENTIALING (Amends the timelines related to healthcare provider credentialing.)

H8310

2026 -- H 8310
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LC006085
========

STATE OF RHODE ISLAND
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2026
____________
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES --
HEALTHCARE PROVIDER CREDENTIALING

Introduced By:
Representatives Place, Hopkins, Santucci, Kislak, McNamara, Cotter,
Shanley, Stewart, Noret, and Knight

Date Introduced:
March 18, 2026

Referred To:
House Health & Human Services
It is enacted by the General Assembly as follows:
1
SECTION 1. Section 27-18-83 of the General Laws in Chapter 27-18 entitled "Accident
2
and Sickness Insurance Policies" is hereby amended to read as follows:
3

27-18-83. Healthcare provider credentialing.
4
(a) For applications received on or after January 1, 2018, a healthcare entity or health plan
5
operating in the state shall be required to issue a decision regarding the credentialing of a healthcare
6
provider as soon as practicable, but no later than
forty-five (45)

thirty (30)
calendar days after the
7
date of receipt of a complete credentialing application.
For any provider already credentialed with
8
Medicare, the timeline shall be ten (10) business days.
9
(b) For minor changes to the demographic information of an individual healthcare provider
10
who is already credentialed with a particular healthcare entity or health plan, such healthcare entity
11
or health plan shall complete such change within
seven (7)

five (5)
business days of receipt of the
12
healthcare provider’s request. Minor changes to demographic information requested by individual
13
providers shall be submitted in the timeframe, and manner required by the healthcare entity or
14
health plan, and shall include all supporting documentation required by the particular healthcare
15
entity or health plan. For purposes of this section, minor changes to the information profile of a
16
healthcare provider shall include, but not be limited to, changes of address and changes to a
17
healthcare provider’s tax identification number.
18
(c)
Each healthcare entity or health plan shall establish a written standard defining what

1
elements constitute a complete credentialing application and shall distribute this standard with the
2
written version of the credentialing application and make such standard available on the healthcare
3
entity’s or health plan’s website.

If the payer fails to meet the timeline in subsection (a) of this
4
section, the provider shall be deemed provisionally credentialed, and the payer shall reimburse the
5
provider retroactively for all covered services rendered from the date the completed application
6
was received.
7
(d) Each healthcare entity or health plan shall respond to inquiries by the applicant
8
regarding the status of an application.
9
(1) Each healthcare entity or health plan shall provide the applicant with automated
10
application status updates, at least once every fifteen (15) calendar days, informing the applicant of
11
any missing application materials until the application is deemed complete;
12
(2) Each healthcare entity or health plan shall inform the applicant within five (5) business
13
days that the credentialing application is complete; and
14
(3) If the healthcare entity or health plan denies a credentialing application, the healthcare
15
entity or health plan shall notify the healthcare provider in writing and shall provide the healthcare
16
provider with any and all reasons for denying the credentialing application.
17
(e) The effective date for billing privileges for healthcare providers under a particular
18
healthcare entity or health plan shall be the next business day following the date of approval of the
19
credentialing application.
20
(f) For applications received from resident graduates on or after January 1, 2018, a
21
healthcare entity or health plan shall offer a transitional or conditional approval process such that a
22
resident graduate who has submitted an otherwise complete application and met all other criteria,
23
may be conditionally approved, effective upon successful graduation from the training program.
24
(g) For the purposes of this section, the following definitions apply:
25
(1) “Complete credentialing application” means all the requested material has been
26
submitted.
27
(2) “Date of receipt” means the date the healthcare entity or health plan receives the
28
completed credentialing application whether via electronic submission or as a paper application.
29
(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or
30
medical or dental service corporation or plan or health maintenance organization, or a contractor
31
as defined in § 23-17.13-2 [repealed] that operates a health plan.
32
(4) “Healthcare provider” means a healthcare professional.
33
(5) “Health plan” means a plan operated by a healthcare entity that provides for the delivery
34
of healthcare services to persons enrolled in those plans through:

LC006085 - Page 2 of 9
1
(i) Arrangements with selected providers to furnish healthcare services; and
2
(ii) Financial incentives for persons enrolled in the plan to use the participating providers
3
and procedures provided for by the health plan.
4

(h) The office of the health insurance commissioner shall enforce the provisions of this
5
chapter and may impose administrative penalties consistent with its existing authority under title
6
27. Non-compliant contract provisions are void. The commissioner shall adopt rules and
7
regulations to implement this chapter and shall require payers to submit quarterly reports on
8
credentialing timelines.
9
SECTION 2. Section 27-19-74 of the General Laws in Chapter 27-19 entitled "Nonprofit
10
Hospital Service Corporations" is hereby amended to read as follows:
11

27-19-74. Healthcare provider credentialing.
12
(a) For applications received on or after January 1, 2018, a healthcare entity or health plan
13
operating in the state shall be required to issue a decision regarding the credentialing of a healthcare
14
provider as soon as practicable, but no later than
forty-five (45)

thirty (30)
calendar days after the
15
date of receipt of a complete credentialing application.
For any provider already credentialed with
16
Medicare, the timeline shall be ten (10) business days.
17
(b) For minor changes to the demographic information of an individual healthcare provider
18
who is already credentialed with a particular healthcare entity or health plan, such healthcare entity
19
or health plan shall complete such change within
seven (7)

five (5)
business days of receipt of the
20
healthcare provider’s request. Minor changes to demographic information requested by individual
21
providers shall be submitted in the timeframe, and manner required by the healthcare entity or
22
health plan, and shall include all supporting documentation required by the particular healthcare
23
entity or health plan. For purposes of this section, minor changes to the information profile of a
24
healthcare provider shall include, but not be limited to, changes of address and changes to a
25
healthcare provider’s tax identification number.
26
(c)
Each healthcare entity or health plan shall establish a written standard defining what
27
elements constitute a complete credentialing application and shall distribute this standard with the
28
written version of the credentialing application and make such standard available on the healthcare
29
entity’s or health plan’s website.

If the payer fails to meet the timeline in subsection (a) of this
30
section, the provider shall be deemed provisionally credentialed, and the payer shall reimburse the
31
provider retroactively for all covered services rendered from the date the completed application
32
was received.
33
(d) Each healthcare entity or health plan shall respond to inquiries by the applicant
34
regarding the status of an application.

LC006085 - Page 3 of 9
1
(1) Each healthcare entity or health plan shall provide the applicant with automated
2
application status updates, at least once every fifteen (15) calendar days, informing the applicant of
3
any missing application materials until the application is deemed complete;
4
(2) Each healthcare entity or health plan shall inform the applicant within five (5) business
5
days that the credentialing application is complete; and
6
(3) If the healthcare entity or health plan denies a credentialing application, the healthcare
7
entity or health plan shall notify the healthcare provider in writing and shall provide the healthcare
8
provider with any and all reasons for denying the credentialing application.
9
(e) The effective date for billing privileges for healthcare providers under a particular
10
healthcare entity or health plan shall be the next business day following the date of approval of the
11
credentialing application.
12
(f) For applications received from resident graduates on or after January 1, 2018, a
13
healthcare entity or health plan shall offer a transitional or conditional approval process such that a
14
resident graduate who has submitted an otherwise complete application and met all other criteria,
15
may be conditionally approved, effective upon successful graduation from the training program.
16
(g) For the purposes of this section, the following definitions apply:
17
(1) “Complete credentialing application” means all the requested material has been
18
submitted.
19
(2) “Date of receipt” means the date the healthcare entity or health plan receives the
20
completed credentialing application whether via electronic submission or as a paper application.
21
(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or
22
medical or dental service corporation or plan or health maintenance organization, or a contractor
23
as defined in § 23-17.13-2 [repealed] that operates a health plan.
24
(4) “Healthcare provider” means a healthcare professional.
25
(5) “Health plan” means a plan operated by a healthcare entity that provides for the delivery
26
of healthcare services to persons enrolled in those plans through:
27
(i) Arrangements with selected providers to furnish healthcare services; and
28
(ii) Financial incentives for persons enrolled in the plan to use the participating providers
29
and procedures provided for by the health plan.
30

(h) The office of the health insurance commissioner shall enforce the provisions of this
31
chapter and may impose administrative penalties consistent with its existing authority under title
32
27. Non-compliant contract provisions are void. The commissioner shall adopt rules and
33
regulations to implement this chapter and shall require payers to submit quarterly reports on
34
credentialing timelines.

LC006085 - Page 4 of 9
1
SECTION 3. Section 27-20-70 of the General Laws in Chapter 27-20 entitled "Nonprofit
2
Medical Service Corporations" is hereby amended to read as follows:
3

27-20-70. Healthcare provider credentialing.
4
(a) For applications received on or after January 1, 2018, a healthcare entity or health plan
5
operating in the state shall be required to issue a decision regarding the credentialing of a healthcare
6
provider as soon as practicable, but no later than
forty-five (45)

thirty (30)
calendar days after the
7
date of receipt of a complete credentialing application.
For any provider already credentialed with
8
Medicare, the timeline shall be ten (10) business days.
9
(b) For minor changes to the demographic information of an individual healthcare provider
10
who is already credentialed with a particular healthcare entity or health plan, the healthcare entity
11
or health plan shall complete the change within
seven (7)

five (5)
business days of receipt of the
12
healthcare provider’s request. Minor changes to demographic information requested by individual
13
providers shall be submitted in the timeframe, and manner required by the healthcare entity or
14
health plan, and shall include all supporting documentation required by the particular healthcare
15
entity or health plan. For purposes of this section, minor changes to the information profile of a
16
healthcare provider shall include, but not be limited to, changes of address and changes to a
17
healthcare provider’s tax identification number.
18
(c)
Each healthcare entity or health plan shall establish a written standard defining what
19
elements constitute a complete credentialing application and shall distribute this standard with the
20
written version of the credentialing application and make the standard available on the healthcare
21
entity’s or health plan’s website.

If the payer fails to meet the timeline in subsection (a) of this
22
section, the provider shall be deemed provisionally credentialed, and the payer shall reimburse the
23
provider retroactively for all covered services rendered from the date the completed application
24
was received.
25
(d) Each healthcare entity or health plan shall respond to inquiries by the applicant
26
regarding the status of an application.
27
(1) Each healthcare entity or health plan shall provide the applicant with automated
28
application status updates, at least once every fifteen (15) calendar days, informing the applicant of
29
any missing application materials until the application is deemed complete;
30
(2) Each healthcare entity or health plan shall inform the applicant within five (5) business
31
days that the credentialing application is complete; and
32
(3) If the healthcare entity or health plan denies a credentialing application, the healthcare
33
entity or health plan shall notify the healthcare provider in writing and shall provide the healthcare
34
provider with any and all reasons for denying the credentialing application.

LC006085 - Page 5 of 9
1
(e) The effective date for billing privileges for healthcare providers under a particular
2
healthcare entity or health plan shall be the next business day following the date of approval of the
3
credentialing application.
4
(f) For applications received from resident graduates on or after January 1, 2018, a
5
healthcare entity or health plan shall offer a transitional or conditional approval process such that a
6
resident graduate who has submitted an otherwise complete application and met all other criteria,
7
may be conditionally approved, effective upon successful graduation from the training program.
8
(g) For the purposes of this section, the following definitions apply:
9
(1) “Complete credentialing application” means all the requested material has been
10
submitted.
11
(2) “Date of receipt” means the date the healthcare entity or health plan receives the
12
completed credentialing application whether via electronic submission or as a paper application.
13
(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or
14
medical or dental service corporation or plan or health maintenance organization, or a contractor
15
as defined in § 23-17.13-2 [repealed] that operates a health plan.
16
(4) “Healthcare provider” means a healthcare professional.
17
(5) “Health plan” means a plan operated by a healthcare entity that provides for the delivery
18
of healthcare services to persons enrolled in those plans through:
19
(i) Arrangements with selected providers to furnish healthcare services; and
20
(ii) Financial incentives for persons enrolled in the plan to use the participating providers
21
and procedures provided for by the health plan.
22

(h) The office of the health insurance commissioner shall enforce the provisions of this
23
chapter and may impose administrative penalties consistent with its existing authority under title
24
27. Non-compliant contract provisions are void. The commissioner shall adopt rules and
25
regulations to implement this chapter and shall require payers to submit quarterly reports on
26
credentialing timelines.
27
SECTION 4. Section 27-41-87 of the General Laws in Chapter 27-41 entitled "Health
28
Maintenance Organizations" is hereby amended to read as follows:
29

27-41-87. Healthcare provider credentialing.
30
(a) For applications received on or after January 1, 2018, a healthcare entity or health plan
31
operating in the state shall be required to issue a decision regarding the credentialing of a healthcare
32
provider as soon as practicable, but no later than
forty-five (45)

thirty (30)
calendar days after the
33
date of receipt of a complete credentialing application.
For any provider already credentialed with
34
Medicare, the timeline shall be ten (10) business days.

LC006085 - Page 6 of 9
1
(b) For minor changes to the demographic information of an individual healthcare provider
2
who is already credentialed with a particular healthcare entity or health plan, the healthcare entity
3
or health plan shall complete the change within
seven (7)

five (5)
business days of receipt of the
4
healthcare provider’s request. Minor changes to demographic information requested by individual
5
providers shall be submitted in the time frame, and manner required by the healthcare entity or
6
health plan, and shall include all supporting documentation required by the particular healthcare
7
entity or health plan. For purposes of this section, minor changes to the information profile of a
8
healthcare provider shall include, but not be limited to, changes of address and changes to a
9
healthcare provider’s tax identification number.
10
(c)
Each healthcare entity or health plan shall establish a written standard defining what
11
elements constitute a complete credentialing application and shall distribute this standard with the
12
written version of the credentialing application and make the standard available on the healthcare
13
entity’s or health plan’s website.

If the payer fails to meet the timeline in subsection (a) of this
14
section, the provider shall be deemed provisionally credentialed, and the payer shall reimburse the
15
provider retroactively for all covered services rendered from the date the completed application
16
was received.
17
(d) Each healthcare entity or health plan shall respond to inquiries by the applicant
18
regarding the status of an application.
19
(1) Each healthcare entity or health plan shall provide the applicant with automated
20
application status updates, at least once every fifteen (15) calendar days, informing the applicant of
21
any missing application materials until the application is deemed complete;
22
(2) Each healthcare entity or health plan shall inform the applicant within five (5) business
23
days that the credentialing application is complete; and
24
(3) If the healthcare entity or health plan denies a credentialing application, the healthcare
25
entity or health plan shall notify the healthcare provider in writing and shall provide the healthcare
26
provider with any and all reasons for denying the credentialing application.
27
(e) The effective date for billing privileges for healthcare providers under a particular
28
healthcare entity or health plan shall be the next business day following the date of approval of the
29
credentialing application.
30
(f) For applications received from resident graduates on or after January 1, 2018, a
31
healthcare entity or health plan shall offer a transitional or conditional approval process such that a
32
resident graduate who has submitted an otherwise complete application and met all other criteria,
33
may be conditionally approved, effective upon successful graduation from the training program.
34
(g) For the purposes of this section, the following definitions apply:

LC006085 - Page 7 of 9
1
(1) “Complete credentialing application” means all the requested material has been
2
submitted.
3
(2) “Date of receipt” means the date the healthcare entity or health plan receives the
4
completed credentialing application whether via electronic submission or as a paper application.
5
(3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or
6
medical or dental service corporation or plan or health maintenance organization, or a contractor
7
as defined in § 23-17.13-2 [repealed] that operates a health plan.
8
(4) “Healthcare provider” means a healthcare professional.
9
(5) “Health plan” means a plan operated by a healthcare entity that provides for the delivery
10
of healthcare services to persons enrolled in those plans through:
11
(i) Arrangements with selected providers to furnish healthcare services; and
12
(ii) Financial incentives for persons enrolled in the plan to use the participating providers
13
and procedures provided for by the health plan.
14

(h) The office of the health insurance commissioner shall enforce the provisions of this
15
chapter and may impose administrative penalties consistent with its existing authority under title
16
27. Non-compliant contract provisions are void. The commissioner shall adopt rules and
17
regulations to implement this chapter and shall require payers to submit quarterly reports on
18
credentialing timelines.
19
SECTION 5. This act shall take effect upon passage.
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LC006085
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LC006085 - Page 8 of 9
EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES --
HEALTHCARE PROVIDER CREDENTIALING
***
1
This act would amend the timelines related to healthcare provider credentialing.
2
This act would take effect upon passage.
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LC006085
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LC006085 - Page 9 of 9