Health care coverage: health care provider credentials.

The requirement for departments to review NCQA standards, adopt regulations, and develop their own standardized credentialing forms by January 1, 2028 is removed. In its place, plans and insurers are directly required to subscribe to and use the existing CAQH credentialing form on and after January 1, 2028.

Provisions requiring the standardized credentialing form to be made electronically available by the department and plans, and that it may be electronically completed and submitted, are removed.

The exemption from the Administrative Procedure Act for department updates to the standardized credentialing form is removed, since there is no longer a department-developed form being updated.

Legislative intent language encouraging coordination between the Department of Managed Health Care and the Department of Insurance in developing standards and forms is removed.

The term 'designee' is replaced throughout with 'delegate' when referring to entities acting on behalf of health care service plans or health insurers.

The bill text was reformatted from the official authenticated chaptered document (with page numbers, state headers, and formal layout) to the web-based display format used on the California legislature's website, including navigation elements, version history links, and restructured headings. No policy content was altered.

Medi-Cal managed care plans are now explicitly excluded from the 90-day credentialing determination requirement in Section 1374.198, meaning state-managed Medi-Cal contracts under Welfare and Institutions Code Chapters 7 and 8 are not subject to the deadline.

Delegates (credentialing agents) must now subscribe to and use the most recent version of the CAQH credentialing form and comply with CAQH credentialing processes. This is a direct mandate rather than relying on the department to adopt a specific form.

Providers are now required to submit their credentialing form and maintain their credentialing information in the CAQH database in a manner consistent with CAQH standards, placing an affirmative obligation on providers themselves.

The department's obligation to update the standardized form is narrowed from tracking CAQH updates plus legal changes to only updating as necessary to comply with changes in laws and regulations, since delegates must now directly use the most recent CAQH version.

The 90-day credentialing requirement is clarified to apply 'within one year of the bill's operative date' in addition to one year after adoption of regulations, providing a clearer start date for compliance.

The term 'designee' is replaced with 'delegate' throughout the bill, changing the terminology used to refer to entities performing credentialing on behalf of health plans and insurers.

The bill no longer requires departments to adopt the CAQH standardized credentialing form. Instead, it requires them to develop a standard credentialing form and only mandates that they consider the existing CAQH form during development. This gives regulators discretion over the final form's content.

Throughout the bill, the 90-day deadline language changed from requiring plans and insurers to 'approve' provider credentials to merely 'make a determination regarding the credentials.' This broadens what counts as meeting the deadline since a denial or other decision now satisfies the requirement, not just an approval.

When the 90-day deadline is missed, the automatic status for the applicant changed from 'conditionally provisionally approved' to simply 'provisionally approved,' removing the conditional qualifier and making the provisional status more straightforward.

New coordination provisions were added requiring the Department of Managed Health Care to coordinate with the Department of Insurance (and vice versa) to ensure consistency in developing credentialing standards and forms across both agencies.

The requirement to update the standardized credentialing form 'every three years' was removed. The new version only requires updates in accordance with CAQH updates or as necessary to comply with changes in laws and regulations, without a fixed frequency.

NCQA's role was narrowed. The old version referenced both CAQH credentialing forms and NCQA credentialing forms. The new version references only CAQH credentialing forms, with NCQA limited to providing health plan accreditation standards and guidelines that the department must review before adopting regulations.

Broadened from 'physician provider credentialing' to 'provider credentialing' throughout, extending coverage to all health care providers, not just physicians.

The standardized credentialing form requirement is now limited to 'full service health care service plans' rather than all health care service plans, narrowing which plans must use the form.

Added 'or their designees' throughout, explicitly covering entities that perform credentialing on behalf of health care service plans and insurers.

Deadline for adopting the standardized credentialing form extended from July 1, 2027 to January 1, 2028, and the effective date for mandatory use shifted accordingly.

The 90-day credentialing requirement now applies 'within one year after adoption of a regulation required under Section 1380.2' (or the corresponding insurance code section), adding a regulatory implementation delay before the deadline takes effect.

Departments would now 'adopt the NCQA standardized credentialing form' rather than 'develop' a new one, replacing a custom form with an existing industry-standard form.

Changed from 'assess and verify the qualifications' to 'approve the credentials,' shifting the standard from a verification process to an approval outcome.

Added requirement that plans and insurers must activate the provider upon successful approval and notify the applicant within 10 days if approval occurs before the end of the 90-day timeline.

Conditional approval now has a specific duration of 120 days, rather than being open-ended as in the prior version.

Added that a completed application includes 'all required third-party verifications,' making it clear that third-party verification time counts toward the 90-day window.

Added a 10-business-day response deadline for providers when plans request additional information to clarify or confirm application details.

Changed exception trigger from 'unless all of the following apply' to 'unless any of the following apply,' meaning only one of the three conditions (licensing discipline, NPDB report, or no prior credentialing in five years) is now needed to deny conditional approval.

The NPDB exception was clarified from 'subject to malpractice pursuant to the National Practitioner Data Bank' to 'has one or more adverse action reports or one or more reports of malpractice payments filed with the National Practitioner Data Bank.'

Added language exempting the standardized credentialing form from the Administrative Procedure Act, allowing faster updates without full APA rulemaking procedures.

The standardized credentialing form is now the CAQH (Council for Affordable Quality Healthcare) form instead of the NCQA form. Both departments must adopt both CAQH and NCQA credentialing forms and health plan accreditation standards and guidelines, rather than just reviewing NCQA requirements.

The conditional approval trigger changed from 'unless all of the following apply' to 'unless any of the following apply.' This means if even one exception (discipline, NPDB report, or no prior credentialing in five years) is present, the 120-day provisional approval does not automatically kick in when the 90-day deadline is missed.

Form updates must now be made 'in accordance with the CAQH updates' in addition to changes in laws, regulations, and guidelines, tying the update cycle directly to the CAQH organization's own revision schedule.

The deadline for adopting the standardized credentialing form was moved from July 1, 2027 to January 1, 2028, giving regulators an additional six months.

The limitation 'for provider contracts issued, amended, or renewed on and after January 1, 2026' was removed from both the health care service plan and health insurer 90-day credentialing provisions. The 90-day requirement now applies to all credentialing regardless of when the contract was issued or last modified.

The bill summary now references the Department of Insurance's regulation of 'disability and health insurers' rather than just 'health insurers,' clarifying the department's broader regulatory role.

The term 'conditionally approved' was changed to 'conditionally provisionally approved,' and 'assess and verify the qualifications' was replaced with 'approve' or 'make a determination regarding the credentials.'

The bill's scope was expanded from covering only physicians to covering all health care providers. References to 'physician credentialing' were changed to 'physician provider credentialing' in both the Department of Managed Health Care section (Health and Safety Code 1380.2) and the Department of Insurance section (Insurance Code 10110.9).

In the standardized credentialing form provisions, the entity that may electronically complete and submit the form was expanded from 'the physician' to 'the physician provider,' allowing all health care providers to use the electronic form.

The restriction on additional information requests was broadened: health care service plans and health insurers may only request additional information to clarify what is on the standardized form, now applying to 'physician providers' rather than just 'physicians.'

A typo in the section reference was corrected: 'forllowing' was changed to 'following' in the placement instruction for new Section 1374.198.