S2777 SCS

An Act concerning certain health care credentials and amending P.L.1997, c.192 and amending and supplementing P.L.2001, c.88.

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. Section 7 of P.L.1997, c.192 (C.26:2S-7) is amended to read as follows:

7. a. (1) Each application for [participation] initial credentialing or credential renewal by a licensed health care professional that is submitted to a carrier which offers a managed care plan shall be reviewed by a committee of the carrier that includes appropriate representation of health care professionals with knowledge in the applicant's scope of professional practice.

(2) A carrier shall make available on its Internet website:

(a) the universal application for initial credentialing and renewal forms; and

(b) an explanation of the credentialing process, including a list of all the documents required for initial credentialing and renewal, and any relevant timelines.

b. Upon receipt of an application submitted by a licensed health care professional for initial credentialing or credential renewal, a committee shall:

(1) deem the application approved if the information included as part of the application demonstrates the license of the health care professional as issued by the relevant State licensing board is in good standing; or

(2) if the application is incomplete, notify the applicant health care professional, within 45 days after the submission of a hardcopy application or 30 days after the submission of an electronic application, specifying in the notice all the information that is missing. If the requested information is submitted by the applicant, the original submission date of the application shall be retained for purposes of any applicable credentialing timeline. Submission of the requested information shall not restart or otherwise extend the applicable period for review of the application.

(cf: P.L.1997, c.192, s.7)

2. Section 1 of P.L.2001, c.88 (C.26:2S-7.1) is amended to read as follows:

1. The Commissioner of Banking and Insurance, in consultation with the New Jersey Association of Health Plans, the Health Insurance Association of America, the Medical Society of New Jersey, the New Jersey Hospital Association, and such other representatives of managed care plans as the commissioner deems appropriate, shall adopt by regulation, a universal [physician] application for [participation form] initial credentialing for use by carriers which offer managed care plans for the purpose of credentialing [physicians] licensed health care professionals who seek to participate in a carrier's provider network and for the purpose of credentialing [physicians] licensed health care professionals who are employed by hospitals or other health care facilities which seek to participate in a carrier's provider network.

The commissioner, in consultation with the New Jersey Association of Health Plans, the Health Insurance Association of America, the Medical Society of New Jersey, the New Jersey Hospital Association and such other representatives of managed care plans as the commissioner deems appropriate, shall also adopt by regulation [a form] an application for renewal of credentialing, which shall be an abbreviated version of the universal application [form]. The renewal [form] application shall be designed to enable a [physician] licensed health care professional to indicate changes in the information provided in the application [form].

The commissioner shall revise the universal [application] and renewal [forms] applications, as necessary, to conform with industry-wide, national standards for credentialing.

In developing the forms, the commissioner shall consult with the Commissioner of Human Services to ensure that the credentialing requirements for [participation] initial credentialing and credential renewal in the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), and the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.) are adequately reflected on the [application] initial credentialing and renewal [forms] applications.

(cf: P.L.2012, c.17, s.295)

3. Section 2 of P.L.2001, c.88 (C.26:2S-7.2) is amended to read as follows:

2. [Within 180 days of the adoption of the forms by regulation pursuant to this act, a] A carrier which offers a managed care plan shall accept the universal [physician] application for [participation form] initial credentialing and credential renewal [form] adopted pursuant to [this act] P.L.2001, c.88 (C.26:2S-7.1 et seq.) for the purpose of credentialing [physicians] licensed health care professionals who seek to participate in the carrier's provider network and for the purpose of credentialing [physicians] licensed health care professionals who are employed by hospitals or other health care facilities which seek to participate in the carrier's provider network.

Nothing in this section shall be construed to prevent a carrier from requesting additional information from an applicant that is not provided for in the universal [application] or renewal [form] applications, as applicable, if the requested information does not duplicate any information included in the applicable [form] application.

(cf: P.L.2001, c.88, s.2)

4. (New section) a. A carrier shall not require a licensed health care professional, who is already credentialed with the carrier and who changes employers or health care facilities within this State, to submit a new initial credentialing or renewal application to participate in the carrier’s network solely on the basis that the professional changed employers or health care facilities, unless the change was the result of sanctions or other discipline imposed on the professional, or the employment of the professional was terminated for cause. This subsection shall apply only to licensed health care professionals credentialed directly by the carrier.

b. A carrier may require a licensed health care professional credentialed through a delegated credentialing entity, pursuant to section 5 of P.L. , c. (C. ) (pending before the Legislature as this bill), to undergo the carrier’s credentialing process upon a change in employer or health care facility.

5. (New section) a. A carrier which offers a managed care plan shall make available for consideration, upon request, a credentialing delegation agreement to a hospital licensed in this State that is under contract with the carrier, provided that the hospital maintains an accreditation and credentialing program that meets nationally recognized standards, including, but not limited to, standards promulgated by the National Committee for Quality Assurance.

b. Nothing in subsection a. of this section shall be construed to require a carrier to enter into a credentialing delegation agreement with any hospital, to delegate credentialing authority where applicable standards are not met, or to limit a carrier’s ability to conduct appropriate oversight of any delegated credentialing arrangement in accordance with applicable accreditation, regulatory, or contractual requirements.

6. This act shall take effect on the 180th day next following the date of enactment, except that the Commissioner of Banking and Insurance may take any anticipatory administrative action in advance as shall be necessary for the implementation of this act.