1 STATE OF OKLAHOMA
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2 2nd Session of the 59th Legislature (2024)
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3 SENATE BILL 1631 By: Coleman
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6 AS INTRODUCED
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7 An Act relating to insurance; amending 36 O.S. 2021,
7 Section 4405.1, which relates to credentialing or
8 recredentialing of health care providers; requiring
8 certain notice following credential application
9 determination; updating statutory language; updating
9 statutory reference; and providing an effective date.
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12 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
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13 SECTION 1. AMENDATORY 36 O.S. 2021, Section 4405.1, is
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14 amended to read as follows:
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15 Section 4405.1. A. As used in this section:
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16 1. a. “Health benefit plan” or “plan” means:
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17 (1) group hospital or medical insurance coverages,
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18 (2) not-for-profit hospital or medical service or
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19 indemnity plans,
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20 (3) prepaid health plans,
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21 (4) health maintenance organizations,
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22 (5) preferred provider plans,
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23 (6) Multiple Employer Welfare Arrangements multiple
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24 employer welfare arrangements (MEWA), or
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 1 (7) employer self-insured plans that are not exempt
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2 pursuant to the federal Employee Retirement
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3 Income Security Act of 1974 (ERISA) provisions,
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4 and
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5 b. the term “health benefit plan” health benefit plan
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6 shall not include:
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7 (1) individual plans,
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8 (2) plans that only provide coverage for a specified
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9 disease, accidental death, or dismemberment for
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10 wages or payments in lieu of wages for a period
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11 during which an employee is absent from work
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12 because of sickness or injury or as a supplement
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13 to liability insurance,
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14 (3) Medicare supplemental policies as defined in
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15 Section 1882(g)(1) of the federal Social Security
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16 Act (42 U.S.C., Section 1395ss),
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17 (4) workers’ compensation insurance coverage,
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18 (5) medical payment insurance issued as a part of a
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19 motor vehicle insurance policy, or
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20 (6) long-term care policies, including nursing home
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21 fixed indemnity policies, unless the Insurance
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22 Commissioner determines that the policy provides
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23 comprehensive benefit coverage sufficient to meet
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24 the definition of a health benefit plan; and
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 1 2. “Credentialing” or “recredentialing”, as applied to
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2 physicians and other health care providers, means the process of
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3 accessing and validating the qualifications of such persons to
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4 provide health care services to the beneficiaries of a health
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5 benefit plan. Credentialing or recredentialing may include, but is
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6 not limited to, an evaluation of licensure status, education,
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7 training, experience, competence and professional judgment.
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8 Credentialing or recredentialing is a prerequisite to the final
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9 decision of a health benefit plan to permit initial or continued
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10 participation by a physician or other health care provider.
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11 B. 1. Any health benefit plan that is offered, issued or
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12 renewed in this state shall provide for credentialing and
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13 recredentialing of physicians and other health care providers based
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14 on criteria provided in the uniform credentialing application
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15 required by Section 1-106.2 of Title 63 of the Oklahoma Statutes.
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16 2. Health benefit plans shall make information on such criteria
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17 available to physician and other health care provider applicants,
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18 participating physicians, and other participating health care
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19 providers and shall provide applicants with a checklist of materials
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20 required in the application process.
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21 3. Physicians or other health care providers under
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22 consideration to provide health care services under a health benefit
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23 plan in this state shall apply for credentialing or recredentialing
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24 on the uniform credentialing application and shall provide the
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 1 documentation as outlined in the plan’s checklist of materials
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2 required in the application process.
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3 C. A health benefit plan shall determine whether a
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4 credentialing or recredentialing application is complete. If an
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5 application is determined to be incomplete, the plan shall notify
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6 the applicant in writing within ten (10) calendar days of receipt of
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7 the application. The written notice shall specify the portion of
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8 the application that is causing a delay in processing and explain
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9 any additional information or corrections needed.
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10 D. 1. In reviewing the application, the health benefit plan
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11 shall evaluate each application according to the plan’s checklist of
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12 required materials that accompanies the application.
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13 2. When an application is deemed complete, the plan shall
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14 initiate requests for primary source verification and malpractice
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15 history within seven (7) calendar days.
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16 3. A malpractice carrier shall have twenty-one (21) calendar
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17 days within which to respond after receipt of an inquiry from a
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18 health benefit plan. Any malpractice carrier that fails to respond
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19 to an inquiry within the time frame may be assessed an
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20 administrative penalty by the Insurance Commissioner.
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21 E. 1. Upon receipt of primary source verification and
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22 malpractice history by the plan, the plan shall determine if the
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23 application is a clean application. If the application is deemed
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24 clean, a plan shall have forty-five (45) calendar days within which
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 1 to credential or recredential a physician or other health care
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2 provider. As used in this paragraph, “clean application” means an
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3 application that has no defect, misstatement of facts,
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4 improprieties, including a lack of any required substantiating
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5 documentation, or particular circumstance requiring special
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6 treatment that impedes prompt credentialing or recredentialing.
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7 2. If a plan is unable to credential or recredential a
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8 physician or other health care provider due to an application’s
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9 application not being clean, the plan may extend the credentialing
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10 or recredentialing process for sixty (60) calendar days. At the end
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11 of sixty (60) calendar days, if the plan is awaiting documentation
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12 to complete the application, the physician or other health care
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13 provider shall be notified of the reason for the delay by certified
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14 mail. The physician or other health care provider may extend the
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15 sixty-day period upon written notice to the plan within ten (10)
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16 calendar days; otherwise the application shall be deemed withdrawn.
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17 In no event shall the entire credentialing or recredentialing
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18 process exceed one hundred eighty (180) calendar days.
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19 3. If an application for credentialing or recredentialing is
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20 denied, the plan shall notify the applicant in writing the reason
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21 for the denial and what corrective actions the applicant may
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22 consider within ten (10) calendar days of the determination to deny
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23 the application.
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 1 4. A health benefit plan shall be prohibited from solely basing
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2 a denial of an application for credentialing or recredentialing on
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3 the lack of board certification or board eligibility and from adding
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4 new requirements solely for the purpose of delaying an application.
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5 4. 5. Any health benefit plan that violates the provisions of
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6 this section may be assessed an administrative penalty by the
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7 Commissioner.
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8 F. Within thirty-one (31) days after a provider has been
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9 credentialed by a health benefit plan following the completion of
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10 the credentialing or recredentialing process pursuant to this
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11 section, the health benefit plan shall consider the provider in-
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12 network for purposes of reimbursement.
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13 SECTION 2. This act shall become effective November 1, 2024.
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15 59-2-2720 RD 1/12/2024 3:46:53 PM
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