NC S431

Insurers must approve or deny health care provider credentialing applications within 60 days of receiving a completed form approved by the Commissioner, or issue a temporary credential if the provider has a valid North Carolina professional license and no history of malpractice claims, substance abuse, mental health issues, or licensing board disciplinary action.

Insurers offering new provider contracts must establish protocols to reimburse providers for covered services from the date their completed credentialing application is received, at the in-network rate, provided the application is eventually approved; reimbursement must be recouped if the application is denied.

For new providers joining existing group practices, insurers must notify applicants of credentialing status within five business days and provide notification of results within 60 days of receiving a completed application; claims held during the pending period must be paid at in-network rates upon approval for services provided after application receipt.

Providers denied credentialing cannot require patients to pay more than the in-network cost-sharing amount that would have applied had the provider been in-network at the time services were rendered.

The Commissioner must adopt a uniform provider credentialing application form, and insurers cannot require applicants to submit information beyond what is required by this form.

The act becomes effective October 1, 2019, for applications received on or after that date.