Health care coverage: physician and provider credentials.

Existing law establishes the California Health and Human Services Agency, which includes departments charged with the administration of health, social, and other human services. Existing law provides for the licensure and regulation of health care service plans by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975, and the regulation of health insurers by the Department of Insurance. Existing law sets forth requirements for provider credentialing by a health care service plan or health insurer. A violation of the requirements of the Knox-Keene Health Care Service Plan Act of 1975 by a health care service plan is a crime. This bill would require the California Health and Human Services Agency to create and maintain a physician credentialing board, with specified membership, and would require the board, on or before July 1, 2027, to develop a standardized credentialing form to be used by all health care service plans and health insurers. The bill would require every health care service plan or health insurer to use the standardized credentialing form, as specified. The bill would not apply the standardized form requirements to specified Medi-Cal managed care contracts with the State Department of Health Care Services. Existing law, for provider contracts issued, amended, or renewed on and after January 1, 2023, requires a health care service plan or disability insurer that provides coverage for mental health and substance use disorders and that credentials health care providers of those services for its networks to assess and verify the qualifications of a health care provider within 60 days after receiving a completed provider credentialing application, and to notify the applicant within 7 business days of receipt of the application to verify receipt and inform the applicant whether the application is complete. This bill, for provider contracts issued, amended, or renewed on and after January 1, 2026, would impose the same requirements on all health care service plans and health insurers that credential health care providers for their networks. Because violation of certain requirements of the bill by a health care service plan would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.