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 assistants request 13 for credentialing within fifty-six calendar days from the date 14 of the request. 15 b. If a physicians, advanced registered nurse 16 practitioners, or physician assistants 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 -1- LSB 1798YH (2) 91 nls/ko 1/ 2
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 insurers receipt of a physicians, advanced registered 11 nurse practitioners, or physician assistants 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 explanations 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 assistants 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 -2- LSB 1798YH (2) 91 nls/ko 2/ 2