58-17-150. Retrospective payment of clean claims for covered services provided by health care professional during credentialing period--Requirements.
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/sd/title-58/chapter-58-17/58-17-150·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
A health insurer shall make retrospective payment for all clean claims submitted by a health care professional after the credentialing period for covered services provided by the health care professional during the credentialing period subject to all of the following:
(1)The credentialing period begins on the application date and ends on the date that the health insurer or other entity responsible for credentialing health care professionals on behalf of the health insurer has made a final determination approving the health care professional's application to be credentialed and notice has been sent;
(2)The health insurer or other entity responsible for credentialing health care professionals on behalf of the health insurer shall, electronically or in writing, notify an applicant of its determination regarding a properly completed application for credentialing within ninety days of receipt of an application containing all information required by the health insurer's credentialing form:
(a)If an incomplete application is received, the health insurer or other entity responsible for credentialing of health care professionals on behalf of the insurer shall notify the health care professional of the incomplete application as soon as possible, but no more than thirty days after receipt of the application. The notification shall itemize all documentation or other information that the insurer or entity must receive to complete the application. The health insurer or other entity responsible for credentialing of health care professionals on behalf of the insurer may request additional information if the information provided by the health care professional to the insurer or other entity responsible for credentialing of health care professionals on behalf of the insurer pursuant to this subsection is inaccurate, incomplete, or unclear;
(b)A health insurer or other entity responsible for credentialing of health care professionals may take additional time beyond the ninety days if a special review is required;
(3)The health care professional may not submit any claim to the health insurer during the credentialing period;
(4)A health insurer may not be required to pay any claim submitted by a health care professional during the credentialing period;
(5)The health insurer's time period for timely submission of claims may not begin until the credentialing period has ended. The health insurer's rules pertaining to timely submission may not be used to deny payment of any clean claim for medical services provided by a health care professional during the credentialing period, so long as the health care professional submits all such claims within the time period required by the health insurer's rules beginning on the date the health care professional receives notice that the healthcare professional is credentialed;
(6)Unless otherwise prohibited by law, after the health care professional is credentialed, the health care professional shall submit all claims to the health insurer for covered services provided by the health care professional during the credentialing period;
(7)After the health care professional is credentialed, a health insurer shall pay or deny all clean claims submitted by the health care professional for covered services provided by the health care professional during the credentialing period.