An Act
ENROLLED SENATE
BILL NO. 1631 By: Coleman of the Senate
and
Tedford of the House
An Act relating to insurance; amending 36 O.S. 2021,
Section 4405.1, which relates to credentialing or
recredentialing of health care providers; requiring
certain notice following credential application
determination; updating statutory language; updating
statutory reference; and providing an effective date .
SUBJECT: Health insurance
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 36 O.S. 2021, Section 4405.1, is
amended to read as follows:
Section 4405.1. A. As used in this section:
1. a. “Health benefit plan” or “plan” means:
(1) group hospital or medical insurance coverages,
(2) not-for-profit hospital or medical service or
indemnity plans,
(3) prepaid health plans,
(4) health maintenance organizations,
(5) preferred provider plans,
ENR. S. B. NO. 1631 Page 2
(6) Multiple Employer Welfare Arrangements multiple
employer welfare arrangements (MEWA), or
(7) employer self-insured plans that are not exempt
pursuant to the federal Employee Retirement
Income Security Act of 1974 (ERISA) provisions,
and
b. the term “health benefit plan” health benefit plan
shall not include:
(1) individual plans,
(2) plans that only provide cov erage for a specified
disease, accidental death, or dismemberment for
wages or payments in lieu of wages for a period
during which an employee is absent from work
because of sickness or injury or as a supplement
to liability insurance,
(3) Medicare supplemental policies as defined in
Section 1882(g)(1) of the federal Social Security
Act (42 U.S.C., Section 1395ss),
(4) workers’ compensation insurance coverage,
(5) medical payment insurance issued as a part of a
motor vehicle insurance policy, or
(6) long-term care policies, including nursing home
fixed indemnity policies, unless the Insurance
Commissioner determines that the policy provides
comprehensive benefit coverage sufficient to meet
the definition of a health benefit plan; and
2. “Credentialing” or “recredentialing”, as applied to
physicians and other health care providers, means the process of
accessing and validating the qualifications of such persons to
provide health care services to the beneficiaries of a health
benefit plan. Credentialing or recredentialing may include, but is
not limited to, an evaluation of licensure status, education,
training, experience, competence and professional judgment.
ENR. S. B. NO. 1631 Page 3
Credentialing or recredentialing is a prerequisite to the final
decision of a health benefit p lan to permit initial or continued
participation by a physician or other health care provider.
B. 1. Any health benefit plan that is offered, issued or
renewed in this state shall provide for credentialing and
recredentialing of physicians and other hea lth care providers based
on criteria provided in the uniform credentialing application
required by Section 1 -106.2 of Title 63 of the Oklahoma Statutes.
2. Health benefit plans shall make information on such criteria
available to physician and other heal th care provider applicants,
participating physicians, and other participating health care
providers and shall provide applicants with a checklist of materials
required in the application process.
3. Physicians or other health care providers under
consideration to provide health care services under a health benefit
plan in this state shall apply for credentialing or recredentialing
on the uniform credentialing application and shall provide the
documentation as outlined in the plan ’s checklist of materials
required in the application process.
C. A health benefit plan shall determine whether a
credentialing or recredentialing application is complete. If an
application is determined to be incomplete, the plan shall notify
the applicant in writing within te n (10) calendar days of receipt of
the application. The written notice shall specify the portion of
the application that is causing a delay in processing and explain
any additional information or corrections needed.
D. 1. In reviewing the application, the health benefit plan
shall evaluate each application according to the plan ’s checklist of
required materials that accompanies the application.
2. When an application is deemed complete, the plan shall
initiate requests for primary source verification and malpractice
history within seven (7) calendar days.
3. A malpractice carrier shall have twenty -one (21) calendar
days within which to respond after receipt of an inquiry from a
ENR. S. B. NO. 1631 Page 4
health benefit plan. Any malpractice carrier that fails to respond
to an inquiry within the time frame may be assessed an
administrative penalty by the Insurance Commissioner.
E. 1. Upon receipt of primary source verification and
malpractice history by the plan, the plan shall determine if the
application is a clean applica tion. If the application is deemed
clean, a plan shall have forty -five (45) calendar days within which
to credential or recredential a physician or other health care
provider. As used in this paragraph, “clean application” means an
application that has n o defect, misstatement of facts,
improprieties, including a lack of any required substantiating
documentation, or particular circumstance requiring special
treatment that impedes prompt credentialing or recredentialing.
2. If a plan is unable to credenti al or recredential a
physician or other health care provider due to an application’s
application not being clean, the plan may extend the credentialing
or recredentialing process for sixty (60) calendar days. At the end
of sixty (60) calendar days, if the plan is awaiting documentation
to complete the application, the physician or other health care
provider shall be notified of the reason for the delay by certified
mail. The physician or other health care provider may extend the
sixty-day period upon writ ten notice to the plan within ten (10)
calendar days; otherwise the application shall be deemed withdrawn.
In no event shall the entire credentialing or recredentialing
process exceed one hundred eighty (180) calendar days.
3. If an application for cred entialing or recredentialing is
denied, the plan shall notify the applicant in writing the reason
for the denial and what corrective actions the applicant may
consider within ten (10) calendar days of the determination to deny
the application.
4. A health benefit plan shall be prohibited from solely basing
a denial of an application for credentialing or recredentialing on
the lack of board certification or board eligibility and from adding
new requirements solely for the purpose of delaying an application .
4. 5. Any health benefit plan that violates the provisions of
this section may be assessed an administrative penalty by the
Commissioner.
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F. Within thirty-one (31) days after a provider has been
credentialed by a health benefit plan following the com pletion of
the credentialing or recredentialing process pursuant to this
section, the health benefit plan shall consider the provider in -
network for purposes of reimbursement.
SECTION 2. This act shall become effective November 1, 2024.
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Passed the Senate the 5th day of March, 2024.
Presiding Officer of the Senate
Passed the House of Representatives the 24th day of April, 2024.
Presiding Officer of the House
of Representatives
OFFICE OF THE GOVERNOR
Received by the Office of the Governor this _______ _____________
day of _________________ __, 20_______, at _______ o'clock _______ M.
By: _________________________________
Approved by the Governor of the State of Oklahoma this _______ __
day of _________________ __, 20_______, at _______ o'clock _______ M.
_________________________________
Governor of the State of Oklahoma
OFFICE OF THE SECRETARY OF STATE
Received by the Office of the Secretary of State this _______ ___
day of _________________ _, 20 _______, at _______ o'clock ___ ____ M.
By: _________________________________