Agencies | Governor
Virginia Regulatory Town Hall
Agency
Virginia Department of Health
Board
State Board of Health
chapter
Regulation for the Certificate of Quality Assurance of Managed Care Health Insurance Plan (MCHIP) Licensees [12 VAC 5 ‑ 408]
Action:
Amend regulations to conform to Ch.703 of the 2018 Acts of Assembly and changes related to Provider Credentialing
 
General Information
Action Summary Chapter 703 (2018 Acts of Assembly) amended the Code of Virginia by adding § 38.2-3407.10:1, which requires health insurance carriers that credential physicians in their networks to establish protocols and procedures for reimbursing new provider applicants for health care services provided to covered persons during the period in which the applicant’s completed credentialing application is pending, provided that the new provider applicant is ultimately approved by the health insurance carrier. The State Board of Health is also exercising its authority under § 32.1-137.2(C) of the Code of Virginia to ensure the protocols and procedures cover non-physician providers, since Managed Care Health Insurance Plan licensees also credential non-physician providers. In order to submit claims to the carrier for services provided during that time period, the new provider applicant must notify the covered person in advance of providing care that the carrier is in the process of obtaining and verifying the required credentialing documentation. Additionally, carriers are not required to reimburse the new provider applicant for any care rendered if the credentialing application is not approved or the carrier is otherwise unwilling to contract with the new provider applicant. If payment is made by the carrier to a new provider applicant or any entity that employs or engages the new provider applicant for a covered service, the patient is only responsible for any copayment, coinsurance, or deductibles permitted under the insurance contract with the carrier or participating provider agreement with the new provider applicant. Existing regulations prohibit providers from seeing covered persons or entering into a contractual relationship with the MCHIP licensee before the credentialing process is complete and thus conflict with the provisions of Ch. 703 (2018).
Chapters Affected Only affects this chapter.
Exempt from APA No, this action is not exempt from Article II of the APA and executive branch review.
RIS Project Yes  [005941]
Associated Mandates Health insurance carriers that credential physicians in their networks to establish protocols and procedures for reimbursing new provider applicants for health care services
Associated Petitions for Rulemaking Recommended Amendments Concerning Provider Credentialing and Recredentialing
New Periodic Review This action will not be used to conduct a new periodic review.
 
Stages
Stages associated with this regulatory action.
Stage ID Stage Type Status
8750 Fast-Track DPB review in progress.
 
Contact Information
Name / Title: Rebekah E. Allen  / Sr. Policy Analyst
Address: Virginia Department of Health
9960 Mayland Drive, Ste. 401
Richmond, VA 23233
Email Address: regulatorycomment@vdh.virginia.gov
Phone: (804)367-2102    FAX: (804)527-4502    TDD: ()-