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An Act To Require Payment by a Carrier for Health Care Services Provided to Enrollees of the Carrier
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §4303, sub-§2, as amended by PL 2013, c. 383, §4, is further amended to read:
 
2. Credentialing.   The credentiallingcredentialing of providers by a carrier is governed by this subsection.
 
A. The granting of credentials must be based on objective standards that are available to providers upon application for credentiallingcredentialing. A carrier shall consult with appropriately qualified health care professionals in developing its credentiallingcredentialing standards.
 
B. All credentiallingcredentialing decisions, including those granting, denying or withdrawing credentials, must be in writing. The provider must be provided with all reasons for the denial of an application for credentiallingcredentialing or the withdrawal of credentials. A withdrawal of credentials must be treated as a provider termination and is subject to the requirements of subsection 3-A.
 
C. A carrier shall establish and maintain an appeal procedure, including the provider's right to a hearing, for dealing with provider concerns relating to the denial of credentiallingcredentialing for not meeting the objective credentiallingcredentialing standards of the plan and the contractual relationship between the carrier and the provider. The superintendent shall determine whether the process provided by a carrier is fair and reasonable. This procedure must be specified in every contract between a carrier and a provider or between a carrier and a provider network if a carrier does not contract with providers individually.
 
D. A carrier shall make credentiallingcredentialing decisions, including those granting or denying credentials, within 60 days of receipt of a completed credentiallingcredentialing application from a provider. The time period for granting or denying credentials may be extended upon written notification from the carrier within 60 days following submission of a completed application stating that information contained in the application requires additional time for verification. All credentiallingcredentialing decisions must be made within 180 days of receipt of a completed application. For the purposes of this paragraph, an application is completed if the application includes all of the information required by the uniform credentiallingcredentialing application used by carriers and providers in this State, such attachments to that application as required by the carrier at the time of application and all corrections required by the carrier. A carrier shall review the entire application before returning it to the provider for corrections with a comprehensive list of all corrections needed at the time the application is first returned to the provider. A carrier may not require that a provider have a home address within the State before accepting an application.
Sec. 2.  24-A MRSA §4303, sub-§2-A  is enacted to read:
 
2-A.  Payment to provider for services rendered during pendency of credentialing.     A carrier offering or renewing a health plan in the State shall pay claims for services rendered to an enrollee by a provider prior to credentials being granted from the date a complete application for credentialing is submitted to the carrier as long as credentials are granted to that provider by the carrier in accordance with the requirements of subsection 2. A provider intending to submit a claim pursuant to this subsection may not submit the claim until the provider has been notified by the carrier whether the provider has been credentialed and of the effective date of any credentials. If a claim is submitted prior to the date credentials are granted, the carrier may process that claim in the same manner as a claim submitted by a provider that has not been credentialed.
 
Effective 90 days following adjournment of the 127th Legislature, First Regular Session, unless otherwise indicated.