HB 544 — An Act providing for the use of certain credentialing applications and for credentialing requirements for health insurers; imposing penalties; and conferring powers and imposing duties on the Insurance Department.

PRINTER'S NO.   540

                   THE GENERAL ASSEMBLY OF PENNSYLVANIA



                       HOUSE BILL
                       No. 544
                                               Session of
                                                 2025

     INTRODUCED BY MENTZER, ROAE AND JAMES, FEBRUARY 10, 2025

     REFERRED TO COMMITTEE ON INSURANCE, FEBRUARY 10, 2025


                                   AN ACT
 1   Providing for the use of certain credentialing applications and
 2      for credentialing requirements for health insurers; imposing
 3      penalties; and conferring powers and imposing duties on the
 4      Insurance Department.
 5      The General Assembly of the Commonwealth of Pennsylvania
 6   hereby enacts as follows:
 7   Section 1.   Short title.
 8      This act shall be known and may be cited as the Health Care
 9   Practitioner Credentialing Act.
10   Section 2.   Definitions.
11      The following words and phrases when used in this act shall
12   have the meanings given to them in this section unless the
13   context clearly indicates otherwise:
14      "CAQH."   The Council for Affordable Quality Healthcare.
15      "CAQH credentialing application."   The application used to
16   collect the credentials data commonly requested by health
17   insurers for purposes of credentialing.
18      "Credentialing."   The process of assessing and validating the
19   qualifications of a health care practitioner, including an
 1   evaluation of licensure status, education, training, experience,
 2   competence and professional judgment.
 3      "Federally qualified health center."       A federally qualified
 4   health center as defined in 42 U.S.C. § 1396d(l)(2)(B) (relating
 5   to definitions) or a federally qualified health center look-
 6   alike that is a participating provider with the Department of
 7   Human Services under the act of June 13, 1967 (P.L.31, No.21),
 8   known as the Human Services Code.
 9      "Health care practitioner."        As defined under section 103 of
10   the act of July 19, 1979 (P.L.130, No.48), known as the Health
11   Care Facilities Act. The term shall include:
12          (1)    A health care practitioner at a federally qualified
13      health center.
14          (2)    An individual who engages in the practice of
15      dentistry as defined in section 2 of the act of May 1, 1933
16      (P.L.216, No.76), known as The Dental Law.
17      "Health insurer."       As follows:
18          (1)    An entity that contracts or offers to contract to
19      provide, deliver, arrange for, pay for or reimburse any of
20      the costs of health care services in exchange for a premium,
21      including a Medicaid managed care organization as defined in
22      42 U.S.C. § 1396b(m)(1)(A) (relating to payment to states),
23      and an entity licensed under any of the following:
24                 (i)     The act of May 17, 1921 (P.L.682, No.284), known
25          as The Insurance Company Law of 1921.
26                 (ii)    The act of December 29, 1972 (P.L.1701,
27          No.364), known as the Health Maintenance Organization
28          Act.
29                 (iii)    40 Pa.C.S. Ch. 61 (relating to hospital plan
30          corporations).

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 1                  (iv)     40 Pa.C.S. Ch. 63 (relating to professional
 2            health services plan corporations).
 3            (2)   The term does not include the following types of
 4      insurance or any combination thereof:
 5                  (i)    Accident only.
 6                  (ii)    Fixed indemnity.
 7                  (iii)    Credit.
 8                  (iv)    Vision.
 9                  (v)    Specified disease.
10                  (vi)    Medicare supplement.
11                  (vii)    Civilian Health and Medical Program of the
12            Uniformed Services supplement policy.
13                  (viii)    Long-term care or disability income.
14                  (ix)    Workers' compensation.
15                  (x)    Automobile medical payment insurance.
16                  (xi)    Hospital indemnity.
17   Section 3.     Utilization of CAQH.
18      All health insurers licensed to do business in this
19   Commonwealth shall be required to accept the CAQH credentialing
20   application or other form designated by the Insurance Department
21   so long as the form is nationally recognized as an appropriate
22   credentialing application when submitted by a health care
23   practitioner for participation in the health insurer's provider
24   panel. All health care practitioners shall use the CAQH or other
25   designated form. An application shall be considered complete if
26   the application is submitted through the CAQH electronic process
27   or other process as designated by the Insurance Department and
28   all required information is provided.
29   Section 4.     Credentialing.
30      (a)   Notice.--Within 10 business days after receiving a CAQH

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 1   credentialing application, the health insurer shall notify the
 2   health care practitioner in writing on whether the application
 3   is complete or incomplete. The health insurer shall state the
 4   reasons why the application is incomplete within the time frame
 5   specified under this subsection.
 6      (b)   Issuance.--The health insurer shall issue a
 7   credentialing determination within 45 business days after
 8   receiving a complete CAQH credentialing application. When a
 9   health care practitioner is not credentialed by a health
10   insurer, the health insurer shall notify the health care
11   practitioner in writing of the reasons for the decision within
12   the time frame specified under this subsection.
13      (c)   Automatic credentialing.--Upon approving a health care
14   practitioner's complete CAQH credentialing application with
15   practices in multiple locations, the health care practitioner
16   shall be automatically credentialed to serve in the health
17   insurer's provider panel in all locations.
18   Section 5.     Penalty.
19      The Insurance Department shall assess an administrative
20   penalty on a health insurer for failure to utilize CAQH, or
21   other designated application, or for intentionally and routinely
22   failing to complete the credentialing process according to
23   section 4. A health insurer may not be subject to an
24   administrative penalty based on a health care practitioner's
25   failure to use or complete an accurate CAQH credentialing
26   application.
27   Section 6.     Rights.
28      Nothing in this act shall be construed to guarantee the
29   rights of a health care practitioner to participate in any
30   health insurer network in this Commonwealth nor require a health

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 1   insurer to accept any willing health care provider to an
 2   insurance network.
 3   Section 7.   Rules and regulations.
 4      The Insurance Department shall promulgate rules and
 5   regulations to administer and enforce this act.
 6   Section 8.   Repeals.
 7      All acts and parts of acts are repealed insofar as they are
 8   inconsistent with this act.
 9   Section 9.   Effective date.
10      This act shall take effect in 180 days.




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