Iowa Admin. Code r. 191-70.10

Current through Register Vol. 47, No. 13, December 25, 2024

Rule 191-70.10 - Credentialing-retrospective payment

(1)Purpose. This rule implements Iowa Code section 514F.6, which provides for the retrospective payment of clean claims for covered services provided by a physician, advanced registered nurse practitioner or physician assistant during the credentialing period, once the physician, advanced registered nurse practitioner or physician assistant is credentialed.

(2)Definitions. For purposes of this rule, the definitions found in Iowa Code section 514F.6 shall apply. In addition, the following definitions shall apply:

"Application date" means the date on which the health insurer or other entity responsible for the credentialing of health care professionals on behalf of the health insurer receives the health care professional's completed application for credentialing.

"Clean claim" means clean claim as defined in Iowa Code section 507B.4A(2)"b."

"Health care professional" means a physician, advanced registered nurse practitioner or physician assistant.

"Health insurer" means the same as a carrier, as defined in Iowa Code section 513B.2(4), that provides health insurance coverage, as defined in Iowa Code section 513B.2(12).

(3)Retrospective payment of clean claims. A health insurer shall make retrospective payment for all clean claims submitted by a health care professional after the credentialing period for covered services provided by the health care professional during the credentialing period subject to all of the following:

a. The credentialing period shall begin on the application date and end on the date the health insurer or other entity responsible for credentialing health care professionals on behalf of the health insurer makes a final determination approving the health care professional's application to be credentialed.

b. The health insurer or other entity responsible for credentialing health care professionals on behalf of the health insurer shall notify an applicant of its determination regarding a properly completed application for credentialing within 90 days of receipt of an application containing all information required by the health insurer's credentialing form.

c. The health care professional shall not submit any claims to the health insurer during the credentialing period.

d. A health insurer shall not be required to pay any claims submitted by a health care professional during the credentialing period.

e. The health insurer's time period for timely submission of claims shall not start until the credentialing period has ended. The health insurer's rules pertaining to timely submission shall not be used to deny payment of any clean claims for medical services provided by a health care professional during the credentialing period, so long as the health care professional submits all such claims within the time period required by the health insurer's rules beginning on the date the health care professional is credentialed.

f. After the health care professional has been credentialed, the health care professional shall submit all claims to the health insurer for covered services provided by the health care professional during the credentialing period.

g. After the health care professional has been credentialed, a health insurer shall pay all clean claims submitted by the health care professional for covered services provided by the health care professional during the credentialing period within the time periods specified in 191-15.32 (507B).

(4)Applicability.

a. This rule shall not apply to services provided by a health care professional that are covered by Medicaid, Medicare, TRICARE, or other health care benefit programs subject to federal regulations regarding eligibility and provider payments.

b. Nothing contained in this rule shall require a health insurer or other entity responsible for credentialing health care professionals on behalf of the health insurer to take any action in violation of the requirements of the National Committee for Quality Assurance (NCQA) or Utilization Review Accreditation Commission (URAC).

c. Nothing contained in this rule shall require a health insurer or other entity responsible for credentialing health care professionals on behalf of the health insurer to credential a health care professional or to permit a noncredentialed health care professional to participate in the health insurer's provider network.

(5)Effective date. This rule shall become effective on July 22, 2009.

Iowa Admin. Code r. 191-70.10

ARC 7880B, lAB 6/17/09, effective 7/22/09; ARC 9038B, lAB 8/25/10, effective 9/29/10

Amended by IAB December 29, 2021/Volume XLIV, Number 13, effective 2/2/2022