ARIZONA STATE SENATE
RESEARCH STAFF
TO: MEMBERS OF THE SENATE
HEALTH & HUMAN SERVICES
COMMITTEE
DATE: February 17, 2025
SUBJECT: Strike everything amendment to S.B. 1291, relating to health insurers; provider
credentialing; claims
Purpose
Effective April 1, 2026, modifies deadlines of the health insurance provider credentialing
process and prescribes requirements for processing of claims.
Background
Health care provider credentialing is the process whereby health care insurers collect,
verify and assess whether a provider meets relevant licensing, education and training requirements
to become or remain a participating provider. Insurers must conclude the process of credentialing
and loading an applicant's information into the insurer's billing system within 100 days of receipt
of an application. Insurers may not deny a claim for a covered service provided to a subscriber by
a participating provider who has a fully executed contract with a network plan if the services are
provided after the date of approval of the credentialing application (A.R.S. §§ 20-3451; 20-3453;
and 20-3456).
A health insurer is a disability insurer, group disability insurer, blanket disability insurer,
health care services organization, hospital service corporation, medical service corporation or
hospital, medical, dental and optometric service corporation, including the insurers designee but
excluding pharmacy benefit managers (A.R.S. § 20-3451).
There is no anticipated fiscal impact to the state General Fund associated with this
legislation.
Provisions
1. Requires health insurers to conclude the provider credentialing process within 60 calendar days
and to load the applicant's information into the billing system within 30 days after the health
insurer receives a complete credentialing application.
2. Requires, within seven calendar days of receiving a credentialing application, a health insurer
to contact the applicant in writing or electronically to acknowledge receipt of the application
and inform the applicant whether the application is complete.
3. Requires insurers to include a detailed list of all incomplete items in incomplete credentialing
application notices.
4. Stipulates that, if a credentialing application is incomplete and requires additional information
from the applicant, the health insurer must contact the applicant within seven calendar days to
acknowledge receipt of the additional information and inform the applicant whether the
application is complete.
MICHAEL MADDEN
LEGISLATIVE RESEARCH ANALYST
HEALTH & HUMAN SERVICES COMMITTEE
Telephone: (602) 926-3171 STRIKER MEMO
S.B. 1291
Page 2
5. Stipulates that, if the time period for processing a credentialing application is tolled while the
health insurer waits for additional information, the health insurer must acknowledge, in writing
or electronically, receipt of the additional information within seven calendar days.
6. Prohibits health insurers from tolling the required application processing time period more than
three times.
7. Allows a health insurer to deem an application withdrawn if, after the third toll, the insurer has
not received a response from the applicant with additional information within 30 calendar days.
8. Requires health insurers to communicate the withdrawal of an application to the applicant
within seven calendar days.
9. Requires credentialing applicants to include the email address of an individual who can address
discrepancies in the application.
10. Allows a provider to receive payment from a health insurer for services provided from the date
included on the notice of complete credentialing application to the date the provider's network
participation contract is executed.
11. Requires health insurers to process a provider's claim as an in-network claim and pay the claim
if the provider:
a) has applied for credentialing and renders a covered service to an individual who is an
eligible health plan member on the date of service;
b) renders the service on or after the date that the health insurer notified the provider of a
complete credentialing application; and
c) does not submit the claim until after the provider has a fully executed network participation
contract with the insurer for the member's health plan network and the insurer has approved
the provider's credentials.
12. Prohibits, for claims submitted within one year after the date of service, health insurers from
denying a provider's claim that is submitted in compliance with statute on the basis that the
claim was not submitted within the contractually required time period.
13. Specifies that health insurers are not required to reimburse an applicant at the in-network rate
for any covered medical services provided by the applicant if the applicant's credentialing
application is not approved or the health care provider is unwilling to contract with the insurer
on mutually acceptable terms.
14. Requires, within a reasonable period before a health care provider provides services to a patient
in a network facility, the provider or the provider's representative to provide a written, dated
disclosure that includes:
a) the name of the billing health care provider;
b) the total estimated cost to be billed by the health care provider or the provider's
representative; and
c) a statement that the provider is not credentialed and is not a contract provider. STRIKER MEMO
S.B. 1291
Page 3
15. Exempts a health insurer that does not credential a provider from civil liability for any act or
omission of the provider in rendering services to a member.
16. Defines complete credentialing application as an application that includes all the information,
any required supporting documentation and a current authorization to access electronic
documentation that a health insurer needs in order to process the credentialing request through
a credentialing system that is developed by a nationally recognized alliance of health plans and
trade associations, including a nonprofit organization that is incorporated as a mutual health
care corporation that is working to streamline the health care business.
17. Modifies the definition of participating provider to include providers that are contracted with
a health insurer to provide health care items or services to subscribers.
18. Makes technical and conforming changes.
19. Becomes effective on April 1, 2026.