PRINTER'S NO. 540
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.544
Session of
2025
INTRODUCED BY MENTZER, ROAE AND JAMES, FEBRUARY 10, 2025
REFERRED TO COMMITTEE ON INSURANCE, FEBRUARY 10, 2025
AN ACT
Providing for the use of certain credentialing applications and
for credentialing requirements for health insurers; imposing
penalties; and conferring powers and imposing duties on the
Insurance Department.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be known and may be cited as the Health Care
Practitioner Credentialing Act.
Section 2. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"CAQH." The Council for Affordable Quality Healthcare.
"CAQH credentialing application." The application used to
collect the credentials data commonly requested by health
insurers for purposes of credentialing.
"Credentialing." The process of assessing and validating the
qualifications of a health care practitioner, including an
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19 evaluation of licensure status, education, training, experience,
competence and professional judgment.
"Federally qualified health center." A federally qualified
health center as defined in 42 U.S.C. § 1396d(l)(2)(B) (relating
to definitions) or a federally qualified health center look-
alike that is a participating provider with the Department of
Human Services under the act of June 13, 1967 (P.L.31, No.21),
known as the Human Services Code.
"Health care practitioner." As defined under section 103 of
the act of July 19, 1979 (P.L.130, No.48), known as the Health
Care Facilities Act. The term shall include:
(1) A health care practitioner at a federally qualified
health center.
(2) An individual who engages in the practice of
dentistry as defined in section 2 of the act of May 1, 1933
(P.L.216, No.76), known as The Dental Law.
"Health insurer." As follows:
(1) An entity that contracts or offers to contract to
provide, deliver, arrange for, pay for or reimburse any of
the costs of health care services in exchange for a premium,
including a Medicaid managed care organization as defined in
42 U.S.C. § 1396b(m)(1)(A) (relating to payment to states) ,
and an entity licensed under any of the following:
(i) The act of May 17, 1921 (P.L.682, No.284), known
as The Insurance Company Law of 1921.
(ii) The act of December 29, 1972 (P.L.1701,
No.364), known as the Health Maintenance Organization
Act.
(iii) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations).
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30 (iv) 40 Pa.C.S. Ch. 63 (relating to professional
health services plan corporations).
(2) The term does not include the following types of
insurance or any combination thereof:
(i) Accident only.
(ii) Fixed indemnity.
(iii) Credit.
(iv) Vision.
(v) Specified disease.
(vi) Medicare supplement.
(vii) Civilian Health and Medical Program of the
Uniformed Services supplement policy.
(viii) Long-term care or disability income.
(ix) Workers' compensation.
(x) Automobile medical payment insurance.
(xi) Hospital indemnity.
Section 3. Utilization of CAQH.
All health insurers licensed to do business in this
Commonwealth shall be required to accept the CAQH credentialing
application or other form designated by the Insurance Department
so long as the form is nationally recognized as an appropriate
credentialing application when submitted by a health care
practitioner for participation in the health insurer's provider
panel. All health care practitioners shall use the CAQH or other
designated form. An application shall be considered complete if
the application is submitted through the CAQH electronic process
or other process as designated by the Insurance Department and
all required information is provided.
Section 4. Credentialing.
(a) Notice.--Within 10 business days after receiving a CAQH
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30 credentialing application, the health insurer shall notify the
health care practitioner in writing on whether the application
is complete or incomplete. The health insurer shall state the
reasons why the application is incomplete within the time frame
specified under this subsection.
(b) Issuance.--The health insurer shall issue a
credentialing determination within 45 business days after
receiving a complete CAQH credentialing application. When a
health care practitioner is not credentialed by a health
insurer, the health insurer shall notify the health care
practitioner in writing of the reasons for the decision within
the time frame specified under this subsection.
(c) Automatic credentialing.--Upon approving a health care
practitioner's complete CAQH credentialing application with
practices in multiple locations, the health care practitioner
shall be automatically credentialed to serve in the health
insurer's provider panel in all locations.
Section 5. Penalty.
The Insurance Department shall assess an administrative
penalty on a health insurer for failure to utilize CAQH, or
other designated application, or for intentionally and routinely
failing to complete the credentialing process according to
section 4. A health insurer may not be subject to an
administrative penalty based on a health care practitioner's
failure to use or complete an accurate CAQH credentialing
application.
Section 6. Rights.
Nothing in this act shall be construed to guarantee the
rights of a health care practitioner to participate in any
health insurer network in this Commonwealth nor require a health
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30 insurer to accept any willing health care provider to an
insurance network.
Section 7. Rules and regulations.
The Insurance Department shall promulgate rules and
regulations to administer and enforce this act.
Section 8. Repeals.
All acts and parts of acts are repealed insofar as they are
inconsistent with this act.
Section 9. Effective date.
This act shall take effect in 180 days.
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