Amend Regulation after Enactment of Chapters 376 and 377 of the 2023 Acts of Assembly
|Chapters 376 and 377 of the 2023 Acts of Assembly amend and reenact § 38.2-3407.10:1 of the Code of Virginia, which outlines requirements for carriers that credential physicians, mental health professionals, or other providers in their network. The legislation requires carriers to establish protocols for processing new provider credentialing applications and reimburse new provider applicants for health care services provided to covered persons during the period when their completed credentialing application is pending. This includes carrier notification to the applicant when the application is received, to approve or deny the application within 60 days of receiving a completed application, to adjudicate and pay claims for services rendered during the pending application period no later than 40 days after the new provider applicant is credentialed and contracted, and to pay any reimbursement at the in-network rate. These protocols and procedures only apply if a contractual relationship exists between the carrier and the new provider applicant or entity for whom the new provider applicant is employed or engaged. Additionally, beginning January 1, 2024, a new provider applicant's application is deemed complete within 30 days of the carrier receiving the application, unless the carrier has provided notice that the application is not complete.
Chapters 376 and 377 of the 2023 Acts of Assembly further directs the promulgation of regulations to implement the legislation within 280 days of its enactment date. This exempt action is being utilized to conform 12VAC5-408 to the statutory language and to meet the prescribed regulatory deadline.
Only affects this chapter.
|Executive Branch Review
This Action is exempt from Article 2 of the Administrative Process Act, but falls within the Executive Branch and
will be reviewed by the Governor's Office.
Health insurance; online credentialing system, processing of new applications.
|New Periodic Review
This action will not be used to conduct a new periodic review.
Stages associated with this regulatory action.
|Stage complete. This regulation became effective on 11/22/2023.
This person is the primary contact for this chapter.
Name / Title:
Senior Policy Analyst
9960 Mayland Dr., Suite 401