Sections 44-7001 to 44-7013 shall be known and may be cited as the Health Care Professional Credentialing Verification Act.

The Health Care Professional Credentialing Verification Act requires a health carrier to establish a comprehensive health care professional credentialing verification program to ensure that its participating health care professionals meet specific minimum standards of professional qualification. The standards set out in the act address the initial credentialing verification and subsequent recredentialing process.

For purposes of the Health Care Professional Credentialing Verification Act:

(1) Closed plan means a managed care plan that requires a covered person to use participating providers under the terms of the managed care plan;

(2) Covered person means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan;

(3) Credentialing verification means the process of obtaining and verifying information about a health care professional, and evaluating that health care professional, when that health care professional applies to become a participating provider in a managed care plan offered by a health carrier;

(4) Director means the Director of Insurance;

(5) Facility means an institution providing health care services or a health care setting, including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory, and imaging centers, and rehabilitation and other therapeutic health settings. Facility does not include physicians' offices;

(6) Health benefit plan means a policy, contract, certificate, or agreement entered into, offered, or issued by any person to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. Health benefit plan does not include workers' compensation insurance coverage;

(7) Health care professional means a physician or other health care practitioner licensed, certified, or registered to perform specified health services consistent with state law;

(8) Health care provider or provider means a health care professional or a facility;

(9) Health care services or health services means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease;

(10) Health carrier means an entity that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a prepaid limited health service organization, a prepaid dental service corporation, or any other entity providing a plan of health insurance, health benefits, or health care services. Health carrier does not include a workers' compensation insurer, risk management pool, or self-insured employer who contracts for services to be provided through a managed care plan certified pursuant to section 48-120.02;

(11) Managed care plan means a health benefit plan, including closed plans and open plans, that either requires a covered person to use or creates financial incentives by providing a more favorable deductible, coinsurance, or copayment level for a covered person to use health care providers managed, owned, under contract with, or employed by the health carrier;

(12) Open plan means a managed care plan other than a closed plan that provides incentives, including financial incentives, for covered persons to use participating providers under the terms of the managed care plan;

(13) Participating provider means a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier;

(14) Person means an individual, a corporation, a partnership, an association, a joint venture, a joint-stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing;

(15) Primary verification means verification by the health carrier of a health care professional's credentials based upon evidence obtained from the issuing source of the credential; and

(16) Secondary verification means verification by the health carrier of a health care professional's credentials based upon evidence obtained by means other than direct contact with the issuing source of the credential, such as copies of certificates provided by the applying health care professional.

The Health Care Professional Credentialing Verification Act applies to health carriers that offer closed plans or combination plans having a closed component.

The director may recognize accreditation by one or more nationally recognized private accrediting entities, with established and maintained standards, as evidence of meeting some or all of the requirements of the Health Care Professional Credentialing Verification Act. A recognized accrediting entity shall make available to the director its current standards to demonstrate that the entity's standards meet or exceed this state's requirements. The health carrier may provide the director with documentation that a managed care plan has been accredited by the entity.

(1) A health carrier shall:

(a) Establish written policies and procedures for credentialing verification of all health care professionals with whom the health carrier contracts and apply these standards consistently;

(b) Verify the credentials of a health care professional before entering into a contract with that health care professional. The medical director of the health carrier or other designated health care professional shall have responsibility for, and shall participate in, credentialing verification;

(c) Establish a credentialing verification committee consisting of licensed physicians and other health care professionals to review credentialing verification information and supporting documents and make decisions regarding credentialing verification;

(d) Make available for review by the applying health care professional upon written request all application and credentialing verification policies and procedures;

(e) Retain all records and documents relating to a health care professional's credentialing verification process for at least five years; and

(f) Keep confidential all information obtained in the credentialing verification process except as otherwise provided by law.

(2) Nothing in the Health Care Professional Credentialing Verification Act shall be construed to require a health carrier to select a provider as a participating provider solely because the provider meets the health carrier's credentialing verification standards or to prevent a health carrier from utilizing separate or additional criteria in selecting the health care professionals with whom it contracts.

(3) The policies and procedures for credentialing verification shall be available for review by the director, and, in the case of a health maintenance organization, shall also be available for review by the chief medical officer, if one is appointed pursuant to section 81-3115, and if not, then the Director of Public Health.

A health carrier shall:

(1) Obtain primary verification of at least the following information about the applicant:

(a) Current license, certificate, or registration to practice a health care profession in this state and history of licensure, certification, or registration;

(b) Current level of professional liability coverage, if applicable;

(c) Status of hospital privileges, if applicable;

(d) Specialty board certification status, if applicable;

(e) Current federal Drug Enforcement Agency registration certificate, if applicable;

(f) Graduation from a health care professional school; and

(g) Completion of postgraduate training, if applicable;

(2) Obtain, subject to either primary or secondary verification at the health carrier's discretion:

(a) The health care professional's licensure, certification, or registration history in this and all other states;

(b) The health care professional's malpractice history; and

(c) The health care professional's practice history;

(3) At least every three years obtain primary verification of a participating health care professional's:

(a) Current license, certificate, or registration to practice a health care profession in this state;

(b) Current level of professional liability coverage, if applicable;

(c) Status of hospital privileges, if applicable;

(d) Current federal Drug Enforcement Agency registration certificate, if applicable; and

(e) Specialty board certification status, if applicable; and

(4) Require all participating providers to notify the health carrier of changes in the status of any of the items listed in this section at any time and identify for participating providers the individual to whom they should report changes in the status of an item listed in this section.

(1) A health carrier shall provide a health care professional the opportunity to review and correct information submitted in support of that health care professional's credentialing verification application as set forth below.

(2)(a) Each health care professional who is subject to the credentialing verification process shall have the right to review all information, including the source of that information, obtained by the health carrier to satisfy the requirements of the Health Care Professional Credentialing Verification Act during the health carrier's credentialing process.

(b) A health carrier shall notify a health care professional of any information obtained during the health carrier's credentialing verification process that does not meet the health carrier's credentialing verification standards or that varies substantially from the information provided to the health carrier by the health care professional, except that the health carrier shall not be required to reveal the source of information if the information is not obtained to meet the requirements of the act or if disclosure is prohibited by law.

(c) A health care professional shall have the right to correct any erroneous information. A health carrier shall have a formal process by which a health care professional may submit supplemental or corrected information to the health carrier's credentialing verification committee and request a reconsideration of the health care professional's credentialing verification application if the health care professional feels that the health carrier's credentialing verification committee has received information that is incorrect or misleading. Supplemental information shall be subject to confirmation by the health carrier.

Whenever a health carrier contracts to have another entity perform the credentialing functions required by the Health Care Professional Credentialing Verification Act or applicable rules and regulations, the director shall hold the health carrier responsible for monitoring the activities of the entity with which it contracts and for ensuring that the requirements of the act and applicable rules and regulations are met.

If the director finds that any health carrier doing business in this state is engaging in any violation of the Health Care Professional Credentialing Verification Act and that a proceeding in respect thereto would be in the public interest, the director shall issue and serve upon such health carrier a statement of the charges in that respect and a notice of hearing thereon, which notice shall set a hearing date not less than ten days after the date of the notice.

If, after the hearing, the director finds a health carrier has violated the Health Care Professional Credentialing Verification Act, the director shall reduce his or her findings to writing and shall issue and cause to be served upon the health carrier charged with the violation a copy of the findings and an order requiring the health carrier to cease and desist from engaging in the violation and the director may order any one or more of the following:

(1) Payment of a monetary penalty of not more than one thousand dollars for each violation, not to exceed an aggregate penalty of thirty thousand dollars, unless the violation was committed flagrantly and in conscious disregard of the Health Care Professional Credentialing Verification Act, in which case the penalty shall not be more than fifteen thousand dollars for each violation, not to exceed an aggregate penalty of one hundred fifty thousand dollars; and

(2) Suspension or revocation of the health carrier's certificate of authority if the health carrier knew or reasonably should have known it was in violation of the act.

Any health carrier who violates a cease and desist order of the director under section 44-7011 may after notice and hearing and upon order of the director be subject to:

(1) A monetary penalty of not more than thirty thousand dollars for each violation, not to exceed an aggregate penalty of one hundred fifty thousand dollars; and

(2) Suspension or revocation of the health carrier's certificate of authority.

The director may adopt and promulgate rules and regulations to carry out the Health Care Professional Credentialing Verification Act.