LRB-4736/1
JPC:cjs
2023 - 2024 LEGISLATURE
2023 ASSEMBLY BILL 1187
April 9, 2024 - Introduced by Representative MCGUIRE. Referred to Committee on
Insurance.
***AUTHORS SUBJECT TO CHANGE***
AN ACT to amend 609.32 (2) (a); and to create 609.32 (2) (am) of the statutes;
relating to: provisional approval as a participating provider in a defined
network health plan.
Analysis by the Legislative Reference Bureau
This bill requires defined network plans to issue provisional approvals to
individual health care providers who submit a completed application, contract, or
letter of intent to become a participating provider in a plan's network and who agree
to the plan's terms for providers of the same type. Defined network plans are health
benefit plans that require or provide incentives for their enrollees to use providers
that are managed, owned, under contract with, or employed by the insurer that offers
the health benefit plan. Defined network plans include such plans as health
maintenance organizations, including, for purposes of this bill, health maintenance
organizations that serve Medical Assistance recipients, and some preferred provider
plans. Current law requires defined network plans to develop a process for selecting
and establishing minimum professional requirements for participating providers,
which must include verifying providers' credentials and the history of any liability
claims made against providers. The bill requires a defined network plan to ensure
that any entity that it contracts with to perform review or verification also complies
with the bill. The bill requires defined network plans to notify providers of the final
approval or denial of participating provider status in writing along with the effective
date of the approval or denial.
A provisional approval under the bill allows the applicant provider to provide
services and obtain reimbursement as if the applicant is a participating provider
1
2
3 - 2 -2023 - 2024 Legislature LRB-4736/1
JPC:cjs
ASSEMBLY BILL 1187
under the plan before the applicant attains final approval to be a participating
provider effective on the date the plan receives the provider's application, contract,
or letter of intent. The bill prohibits a plan from recouping any payments it makes
to a provider during the period the provisional approval is effective. If the plan
ultimately denies the provider's application, contract, or letter of intent, the plan
must reimburse the provider for services provided during the period the provisional
approval was effective for at least two weeks following the date that the provider's
application, contract, or letter of intent is denied.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SECTION 1. 609.32 (2) (a) of the statutes is amended to read:
609.32 (2) (a) A defined network plan shall develop a process for selecting
participating providers, including written policies and procedures that the plan uses
for review and approval of providers. After consulting with appropriately qualified
providers, the plan shall establish minimum professional requirements for its
participating providers. The process for selection shall include verification of a
provider's license or certificate, including the history of any suspensions or
revocations, and the history of any liability claims made against the provider. The
defined network plan shall issue a provisional approval to an individual provider
who submits a completed application, contract, or letter of intent to become a
participating provider and who agrees to comply with the terms of the plan that are
applicable to providers of the same type as the applicant. A health maintenance
organization that serves Medical Assistance recipients shall comply with this
paragraph when considering the selection of a provider who is certified by the
department of health services under the Medical Assistance program. A defined
network plan shall ensure that any entity it contracts with to perform review or
verification of a provider's application, contract, or letter of intent to become a
participating provider complies with this paragraph. A defined network plan shall
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18 - 3 -2023 - 2024 Legislature
LRB-4736/1
JPC:cjs
SECTION 1
ASSEMBLY BILL 1187
notify a provider in writing of the final approval or denial of an application, contract,
or letter of intent to become a participating provider and the effective date of the final
approval or denial.
SECTION 2. 609.32 (2) (am) of the statutes is created to read:
609.32 (2) (am) All of the following apply to a provisional approval issued under
par. (a):
1. The provisional approval shall allow the provider to provide services and
obtain reimbursement under the defined network plan as if the provider was a
participating provider before the provider attains final approval or denial as a
participating provider.
2. The provisional approval is effective on the date the defined network plan
receives the application, contract, or letter of intent.
3. A defined network plan may not recoup any payments to a provider made
during the period a provisional approval is effective.
4. A defined network plan shall reimburse a provider for services provided
during the period the provisional approval was effective for at least 2 weeks following
the date that the provider's application, contract, or letter of intent is denied.
SECTION 3.0Initial applicability.
(1) This act first applies to applications, contracts, and letters of intent to
become a participating provider received by a defined network plan on the effective
date of this subsection.
SECTION 4.0Effective date.
(1) This act takes effect on the first day of the 4th month beginning after
publication.
(END)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25