SLS 10RS-1716 REENGROSSED
Page 1 of 4
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
Regular Session, 2010
SENATE BILL NO. 710
BY SENATOR CHEEK
HEALTH/ACC INSURANCE. Provides relative to payments by a health insurance issuer
for services rendered by a new physician in a physician group and options if such physician
does not meet credentialing requirements. (1/1/11)
AN ACT1
To enact R.S. 22:1874(A)(5), relative to billing by contracted health care providers; to2
provide with respect to the payment to any new provider to the contracted network3
of providers; and to provide for related matters.4
Be it enacted by the Legislature of Louisiana:5
Section 1. R.S. 22:1874(A)(5) is hereby enacted to read as follows: 6
ยง1874. Billing by contracted health care providers7
A. * * *8
(5)(a) Under certain circumstances and when the provisions of9
Subparagraph (b) of this Paragraph are met, a health insurance issuer10
contracting with a group of physicians that bills a health insurance issuer11
utilizing a group identification number, such as the group federal tax12
identification number or the group National Provider Identifier as set forth in13
45 CFR162.402 et seq., shall pay the contracted reimbursement rate of the14
physician group for covered health care services rendered by a new physician15
to the group, without health care provider credentialing as described in R.S.16
22:1009. This provision shall apply in either of the following circumstances:17 SB NO. 710
SLS 10RS-1716 REENGROSSED
Page 2 of 4
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
(i) When the new physician has already been credentialed by the health1
insurance issuer and the physician's credentialing is still active with the issuer.2
(ii) When the health insurance issuer has received the required3
credentialing application and information, including proof of active hospital4
privileges, from the new physician and the issuer has not notified the physician5
group that credentialing of the new physician has been denied.6
(b) A health insurance issuer shall comply with the provisions of7
Subparagraph (a) of this Paragraph no later than thirty days after receipt of a8
written request from the physician group. The written request shall include a9
statement that the physician group agrees that all contract provisions, including10
the provision holding covered persons harmless for charges beyond11
reimbursement by the issuer and deductible, coinsurance and copayments,12
apply to the new physician. Such compliance shall apply to any claims for13
covered services rendered by the new physician to covered persons on dates of14
service no earlier than the date of the written request from the physician group.15
(c) Compliance by a health insurance issuer with the provisions of16
Subparagraph (a) of this Paragraph shall not be construed to mean that a17
physician has been credentialed by an issuer or that the issuer is required to list18
the physician in a directory of contracted physicians.19
(d) If, upon compliance with Subparagraph (a) of this Paragraph, a20
health insurance issuer, completes the credentialing process on the new21
physician and determines that the physician does not meet the issuer's22
credentialing requirements either of the following may occur:23
(i) The health insurance issuer may recover from the physician or the24
physician group an amount equal to the difference between appropriate25
payments for in-network benefits and out-of-network benefits provided that the26
health insurance issuer has notified the applicant physician of the adverse27
determination and provided that the health insurance issuer has initiated action28
regarding such recovery within thirty days of the adverse determination.29 SB NO. 710
SLS 10RS-1716 REENGROSSED
Page 3 of 4
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
(ii) The physician or the physician group may retain any deductible,1
coinsurance or copayment collected or in the process of being collected as of the2
date of receipt of the issuer's determination, so long as the amount is not in3
excess of the amount owed by the insured or enrollee for out-of-network4
services.5
* * *6
Section 2. This Act shall become effective on January 1, 2011.7
The original instrument was prepared by Cheryl Horne. The following digest,
which does not constitute a part of the legislative instrument, was prepared
by Greg Waddell.
DIGEST
Cheek (SB 710)
Proposed law provides that when certain circumstances are met, a health insurance issuer
contracting with a group of physicians that bills a health insurance issuer utilizing a group
identification number shall pay the contracted reimbursement rate of the physician group for
covered health care services rendered by a new physician to the group, without health care
provider credentialing as described in present law in either of the following circumstances:
(1)The new physician has already been credentialed by the health insurance issuer and
such credentialing is still active.
(2)The health insurance issuer has received the new physician's credentialing
application and required documentation, but has not yet notified the physician group
that the new physician's credentialing has been denied.
Proposed law provides that a health insurance issuer shall comply with the provisions of
proposed law no later than 30 days after receipt of a written request from the physician group
and additionally provides for the requirements of the written request.
Proposed law provides that if a health insurance issuer determines that a new physician does
not meet their credentialing requirements, either of the following may occur:
(1)The health insurance issuer may recover an amount equal to the difference between
the in-network benefits payment and the out-of-network benefits payment from the
physician or the physician group, provided notification of the adverse determination
was given to the physician and the health issuer initiated action for such recovery
within 30 days of the adverse determination.
(2)The physician or physician group may retain any deductible, coinsurance, or
copayment collected or in the process of being collected on the date the issuer's
determination is received, if the amount does not exceed the amount owed by the
insured or enrollee for out-of-network services.
Effective January 1, 2011.
(Adds R.S. 22:1874(A)(5)) SB NO. 710
SLS 10RS-1716 REENGROSSED
Page 4 of 4
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
Summary of Amendments Adopted by Senate
Committee Amendments Proposed by Senate Committee on Health and Welfare to
the original bill.
1. Removes provisions which require a health insurance issuer contracting with
a network of providers that bills a health insurance issuer utilizing a group
identification number to pay any new provider to the contracted network of
providers, the contracted reimbursement rate of the network for a period of
180 days from the date of the first bill.
2. Removes provision which required the new provider to the network of
contracted providers to be credentialed by a contracted base health care
facility of the health insurance issuer.
3. Requires that when certain circumstances are met, a health insurance issuer
contracting with a group of physicians that bills a health insurance issuer
utilizing a group identification number shall pay the contracted
reimbursement rate of the physician group for covered health care services
rendered by a new physician to the group.
4. Requires compliance by a health insurance issuer no later than 30 days of
receipt of a written request from the physician group and provides for the
requirements of the written request.
Senate Floor Amendments to engrossed bill.
1. Provides relative to recovery of benefits paid and retention of deductibles,
coinsurance, or copayments collected when a health insurance issuer
determines a physician does not meet credentialing requirements.