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Bill > A5046

NJ A5046

Revises credentialing process for physicians attempting to enter a health insurance carrier's provider network.

summary

Introduced
11/14/2024
In Committee
11/14/2024
Crossed Over
Passed
Dead

Introduced Session

2024-2025 Regular Session

Bill Summary

This bill makes changes to the existing health insurance carrier credentialing process to facilitate transparency and enforcement. First, the bill requires a carrier committee reviewing a credentialing application to notify the applicant within 30 days following submission of the application whether the application is incomplete. If the committee does not notify the applicant of an incomplete application within 30 days, the application is to be deemed complete. In addition, the bill requires carriers to include on their Internet websites the universal participation and renewal forms and an explanation of the credentialing process, including a list of all the documents required for participation and renewal and any expected timelines. The bill also provides that if a physician, while waiting to receive a credential to participate in the provider network of a carrier, is delivering health care services to covered persons within the network, the carrier is required to reimburse the physician for services delivered as of the date the credentialing application was filed, if the application is approved by the carrier. Under the bill, carriers are prohibited from requiring a physician who is already credentialed with the carrier and who changes employers or health care facilities within this State to submit a new application or renewal form to participate in the carrier's network solely on the basis that the physician changed employers or health care facilities. Lastly, the bill authorizes the Department of Banking and Insurance to receive, investigate, and enforce alleged violations of law relating to the credentialing process.

AI Summary

This bill revises the credentialing process for physicians seeking to join a health insurance carrier's provider network by introducing several key improvements. The bill requires carrier committees reviewing credentialing applications to notify applicants within 30 days if their application is incomplete, specifying exactly what information is missing, and deems the application complete if no notification is sent within that timeframe. Carriers must now publish universal participation and renewal forms on their websites, along with a detailed explanation of the credentialing process, including required documents and expected timelines. The bill mandates that carriers reimburse physicians for services provided to network patients while their credentialing application is pending, if the application is ultimately approved. Additionally, physicians who are already credentialed with a carrier and simply change employers or healthcare facilities within the state cannot be required to submit a new application. The Department of Banking and Insurance is authorized to receive and investigate complaints related to the credentialing process, with the power to impose civil penalties on carriers who violate the credentialing rules. Importantly, the bill explicitly prevents individuals from pursuing private legal action for credentialing violations, reserving enforcement exclusively to the department. The bill will take effect 180 days after its enactment, giving carriers time to adjust their processes to comply with the new requirements.

Committee Categories

Business and Industry

Sponsors (14)

Last Action

Introduced, Referred to Assembly Financial Institutions and Insurance Committee (on 11/14/2024)
(1 Companion Bills)

bill text

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bill summary

Document Type Source Location
State Bill Page https://www.njleg.state.nj.us/bill-search/2024/A5046
BillText https://pub.njleg.gov/Bills/2024/A5500/5046_I1.HTM
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