C.R.S. § 10-16-705.7: Timely credentialing of providers by carriers - notice of receipt required - notice of incomplete applications required - delegated credentialing agreements - discrepancies - denials of claims prohibited - disclosures - recredentialing - enforcement - rules - definitions.

(1) As used in this section, unless the context otherwise requires:

(a) "Applicant" means a physician, mental health provider, substance use provider, or psychiatric nurse who submits an application to a carrier to become a participating provider in the carrier's provider network.

(b) "Application" means an applicant's application to become credentialed by a carrier as a participating provider in at least one of the carrier's provider networks.

(c) "Carrier credentialing alliance" means an organization of carriers that share activities or responsibilities pertaining to credentialing.

(d) "Credentialing" or "credential" means the process by which a carrier or its designee collects information concerning an applicant; assesses whether the applicant satisfies the relevant licensing, education, and training requirements to become a participating provider; verifies the assessment; and approves or disapproves the applicant's application.

(e) "Delegated credentialing agreement" means an agreement between a carrier and a designee by which the carrier delegates to the designee activities or responsibilities pertaining to credentialing.

(f) "Designee" means a third party to which a carrier delegates activities or responsibilities pertaining to credentialing.

(g) "Health-care facility" means a facility licensed or certified by the department of public health and environment pursuant to section 25-1.5-103.

(g.5) "Mental health provider" means a mental health entity licensed pursuant to article 1.5 of title 25 or mental health professional licensed or certified pursuant to article 245 of title 12, except for unlicensed psychotherapists regulated pursuant to article 245 of title 12.

(g.9) "Participating mental health provider, substance use provider, or psychiatric nurse" means a mental health provider, substance use provider, or psychiatric nurse who is credentialed by a carrier or its designee to provide health-care items or services to covered persons in at least one of the carrier's provider networks.

(h) "Participating physician" means a physician who is credentialed by a carrier or its designee to provide health-care items or services to covered persons in at least one of the carrier's provider networks.

(h.2) "Participating provider" means a participating physician or a participating mental health provider, substance use provider, or psychiatric nurse.

(i) "Physician" means a physician who is licensed pursuant to article 240 of title 12.

(i.5) "Pre-licensed provider" means a "registrant" as defined in section 12-245-202.

(i.7) "Psychiatric nurse" means a registered professional nurse, as defined in section 12-255-104, who, by virtue of postgraduate education and additional nursing preparation, has gained knowledge, judgment, and skill in psychiatric or mental health nursing.

(j) "Recredentialing" or "recredential" means the process by which a carrier or its designee confirms that a participating provider is in good standing and continues to satisfy the carrier's requirements for participating providers.

(k) "Substance use disorder provider" means a mental health entity licensed pursuant to article 1.5 of title 25 that specializes in treating substance use disorders or a mental health professional licensed or certified pursuant to article 245 of title 12 who specializes in treating substance use disorders, except for unlicensed psychotherapists regulated pursuant to article 245 of title 12.

(2) (a) Within seven calendar days after a carrier receives an application, the carrier shall provide the applicant a receipt in written or electronic form.

(b) Upon receiving an application, a carrier shall promptly determine whether the application is complete. If the carrier determines that the application is incomplete, the carrier shall notify the applicant in writing or by electronic means that the application is incomplete within ten calendar days after the date the carrier received the application. The notice must describe the items that are required to complete the application.

(c) If a carrier receives a completed application but fails to provide the applicant a receipt in written or electronic form within seven calendar days after receiving the completed application, as required by subsection (2)(a) of this section, the carrier shall consider the applicant a participating provider, effective no later than fifty-three calendar days following the carrier's receipt of the application.

(3) (a) A carrier shall conclude the process of credentialing an applicant within sixty calendar days after the carrier receives the applicant's completed application.

(b) A carrier shall provide each applicant written or electronic notice of the outcome of the applicant's credentialing within ten calendar days after the conclusion of the credentialing process.

(c) After concluding the credentialing process for an applicant and making a determination regarding the applicant's application, a carrier shall provide to the applicant, at the applicant's request and as allowed by law, all nonproprietary information pertaining to the application and to the final decision regarding the application.

(4) Notwithstanding any other provision of this section:

(a) A carrier that enters into and complies with the requirements of a delegated credentialing agreement with a health-care facility, which agreement imposes equivalent or higher requirements than those described in this section, is deemed to be in compliance with the requirements of this section with regard to an applicant who works for that facility.

(b) A carrier that participates in and complies with the requirements of a carrier credentialing alliance that imposes equivalent or higher requirements than those described in this section is deemed to be in compliance with the requirements of this section.

(5) A carrier shall correct discrepancies in its provider or network directory within thirty calendar days after receiving a report of the discrepancy from the participating provider. A participating provider shall notify a carrier by mail or the electronic means that the carrier traditionally uses to communicate with the providers in the carrier's provider network of any change in the provider's name, address, telephone number, business structure, or tax identification number within fifteen business days after making the change.

(6) A carrier shall not deny a claim for a medically necessary covered service provided to a covered person if the service:

(a) Is a covered benefit under the covered person's health coverage plan; and

(b) Is provided by a participating provider who is in the carrier's provider network and has concluded the carrier's credentialing process.

(7) A carrier shall make the following nonproprietary information available to all applicants and shall post the information on its website:

(a) The carrier's credentialing policies and procedures;

(b) A list of the information required to be included in an application;

(c) A checklist of materials that must be submitted in the credentialing process;

(d) Designated contact information, including a designated point of contact, an email address, and a telephone number, to which an applicant may address any credentialing inquiries; and

(e) The requirements described in subsection (2) of this section and the authority of the commissioner to enforce the requirements and impose penalties for violations, as described in subsection (10) of this section.

(8) (a) A carrier or its designee may recredential a participating provider if recredentialing is:

(I) Required by federal or state law or by the carrier's accreditation standards; or

(II) Permitted by the carrier's contract with the participating provider.

(b) A carrier shall not require a participating provider to submit an application or participate in a contracting process in order to be recredentialed.

(c) This subsection (8) does not affect the contract termination rights of a carrier or a participating provider.

(9) Except as described in subsection (8) of this section and as may be provided in a contract between a carrier and a participating provider, a carrier shall allow a participating provider to remain credentialed and include the participating provider in the carrier's provider network unless the carrier discovers information indicating that the participating provider no longer satisfies the carrier's guidelines for participation, in which case the carrier shall satisfy the requirements described in section 10-16-705 (5) before terminating the participating provider's participation in the carrier's provider network.

(9.5) A carrier shall not refuse to credential an applicant or terminate a participating provider's participation in a carrier's provider network based solely on the applicant's or participating provider's provision of, or assistance in the provision of, a legally protected health-care activity, as defined in section 12-30-121 (1)(d), in this state, so long as the care provided did not violate Colorado law.

(9.7) (a) A carrier shall reimburse a participating mental health provider, substance use provider, or psychiatric nurse for covered medically necessary treatment, as defined in section 10-16-104 (5.5)(d)(IV), furnished by a pre-licensed provider who is under the supervision of the participating mental health provider, substance use provider, or psychiatric nurse who has satisfied all required supervision rules and criteria.

(b) If a health benefit plan offers out-of-network benefits, the carrier must reimburse the covered person for covered medically necessary treatment, as defined in section 10-16-104 (5.5)(d)(IV), that is provided by an out-of-network pre-licensed provider under the supervision of a nonparticipating mental health provider, substance use provider, or psychiatric nurse in accordance with the terms of coverage applicable to nonparticipating providers under the health benefit plan and the carrier's otherwise applicable requirements, which must be publicly available on the carrier's website, as long as the supervising provider submits documentation evidencing the supervision.

(10) The commissioner shall enforce this section and may adopt rules as necessary to implement this section. Upon receiving more than one complaint from an applicant or a participating provider alleging a violation of this section by a carrier, the commissioner shall investigate the complaints. A carrier that fails to comply with this section or with any rules adopted pursuant to this section is subject to civil penalties that the commissioner may order pursuant to section 10-1-310.