Section 37: Establishes Conditions For Health Insurance Carrier Accreditation and Provider Credentialing
(a) There is hereby established within the division a bureau of managed care. Said bureau shall by regulation establish minimum standards for the accreditation of carriers in the following areas: (1) utilization review; (2) quality management and improvement; (3) credentialing; (4) preventive health services; and (5) compliance with sections 2 to 12, inclusive.
(b) In establishing the minimum standards, the bureau shall consult and use, where appropriate, standards established by national accreditation organizations. Notwithstanding the foregoing, the bureau shall not be bound by the standards established by such organizations, provided, however, that wherever the bureau promulgates standards different from the national standards, it shall: (1) be subject to chapter 30A; (2) state the reason for such variation; and (3) take into consideration any projected compliance costs for such variation. In order to reduce health care costs and improve access to health care services, the bureau shall establish by regulation as a condition of accreditation that carriers use uniform standards and methodologies for credentialing of providers, including any health care provider type licensed under chapter 112 that provide identical services. The division shall, before adopting regulations under this section, consult with the division of health care finance and policy, the department of public health, the group insurance commission, the Centers for Medicare and Medicaid Services and each carrier. Accreditation by the bureau shall be valid for a period of 24 months.
(c) Regulations promulgated by the bureau shall be consistent with and not duplicate or overlap with the regulations promulgated by the office of patient protection in the department of public health established by section 217 of chapter 111.
(d) A carrier that contracts with another entity to perform some or all of the functions governed by this chapter shall be responsible for ensuring compliance by said entity with the provisions of this chapter. Any failure by said entity to meet the requirements of this chapter shall be the responsibility of the carrier to remedy and shall subject the carrier to any and all enforcement actions, including financial penalties, authorized under this chapter.
(e) A carrier may apply to the bureau for deemed accreditation status. A carrier may be deemed to be in compliance with the bureau's standards, and may be so accredited by the bureau, only if the carrier, or an entity with which it contracts: (1) is accredited by a national accreditation organization; (2) is in compliance with all of the requirements of this chapter; and (3) demonstrates compliance with, and has obtained the highest possible rating from said national accreditation organization for: (i) utilization review, (ii) quality management, and (iii) member rights and responsibilities, as promulgated by the bureau pursuant to this chapter. The bureau shall publish by regulation the highest possible rating level in each such category used by every national accreditation organization recognized by the bureau. Nothing in this subsection shall be construed to require a carrier, as a condition of certification, to be in compliance at the highest possible rating with each of the accreditation requirements of a national accreditation organization.
(f) A carrier which is not accredited by the bureau pursuant to this section, and is not otherwise exempt from accreditation, shall not offer for sale, provide, or arrange for the provision of a defined set of health care services to insureds through affiliated and contracting providers or employ utilization review in making decisions about whether services are covered benefits under a health benefit plan.
(g) A carrier shall be exempt from accreditation if in the written opinion of the attorney general, the commissioner of insurance and the commissioner of public health, the health and safety of health care consumers would be materially jeopardized by requiring accreditation of the carrier. Before publishing such written exemption, the attorney general, the commissioner of insurance and the commissioner of public health shall jointly hold at least one public hearing at which testimony from interested parties on the subject of the exemption shall be solicited. A carrier granted such an exemption shall be provisionally accredited and, during such provisional accreditation, shall be subject to review not less than every four months and shall be subject to those requirements of this chapter as deemed appropriate by the commissioner of insurance.
(h) Nothing in this chapter shall relieve any carrier of its obligations pursuant to the applicable provisions of chapters 175, 176A, 176B, 176G and 176I. Compliance with such applicable provisions of chapter 175, 176A, 176B, 176G and 176I shall be a condition of accreditation.
By way of background, the Bureau of Managed Care within DOI determines standards and procedures for accreditation of health insurance carriers. The Bureau must consult with the Division of Health Care Finance and Policy, the Department of Public Health, the Group Insurance Commission, the Centers for Medicare and Medicaid Services, and each health insurance carrier to develop the standards.