HF3921

Purpose

This bill clarifies and standardizes how health plans review and decide on provider credentialing for their networks. It establishes clear timeframes and procedures for what counts as a clean application, how quickly deficiencies must be reported, and how long investigations can take when there are quality or safety concerns.

Main Provisions

• Clean vs. not clean application

  • When a health plan receives a credentialing application, it must determine whether the application is a clean application.
  • If the application is clean, the provider or the clinic/facility that uses the provider must be notified of the date by which the plan will make a determination.

• Deficiencies for not-clean applications

  • If the application is not clean, the health plan must inform the provider of deficiencies or missing information within 3 business days after it is determined not to be clean.

• Timeframe to decide on a clean application

  • The health plan must determine a clean application within 45 days after receiving it, unless the plan identifies substantive quality or safety concerns that require further investigation.

• Extensions for quality or safety concerns

  • If there are substantive quality or safety concerns, the health plan may extend the investigation by up to 30 additional days after notice.

• Outcome: in-network status

  • Once a clean application has been reviewed and approved, the provider is classified as being in the health plan’s provider network.

Significant Changes to Existing Law

• Adds specific deadlines for credentialing actions (3 business days for deficiencies notice; 45 days to decide on a clean application; 30-day extension for investigations).
• Defines and clarifies what constitutes a clean vs. not-clean credentialing application.
• Clarifies the process and timing for when a health plan determines a provider is in-network.

How this affects providers and clinics

• Providers and clinics will have clearer expectations about how long credentialing decisions take and when they will be notified if something is missing.
• The process may speed up in-network status for providers who meet the criteria, while allowing extra time for legitimate quality or safety investigations.

Relevant Terms

clean application; deficiencies; missing information; substantiation; health plan company; health care provider; clinic or facility; provider credentialing; provider network; credentialing determination; time limits; quality or safety concern; investigation; notification; in-network.