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House Bill 4176 History
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ENROLLED
COMMITTEE SUBSTITUTE
for
H. B. 4176
(By Delegates Perdue, Border, Hatfield,
Staggers, Moore, Moye and Rodighiero)
[Passed March 11, 2010; in effect ninety days from passage.]
AN ACT
to amend and reenact §16-1A-1, §16-1A-2, §16-1A-3, §16-1A-4
and §16-1A-5 of the Code of West Virginia, 1931, as amended;
and to amend said code by adding thereto five new sections,
designated §16-1A-6, §16-1A-7, §16-1A-8, §16-1A-9 and
§16-1A-10, all relating to providing for uniform credentialing
for health care practitioners; establishing a single statewide
credentialing verification organization and a uniform
recredentialing calendar; setting forth legislative findings,
defining terms; increasing the membership of the advisory
committee; authorizing the Secretary and Insurance
Commissioner to, no later than July 1, 2015, select and
contract with a qualified credentialing verification
organization that will be the sole source for primary source
verification for all credentialing entities; reviewing
operations of the statewide credentialing verification organization; setting forth qualifications for a credentialing
verification organization; giving preference to a
credentialing verification organization organized within this
state; suspending mandatory use of statewide credentialing
verification organization by credentialing entities by the
Secretary and Insurance Commissioner for certain failures of
the statewide credentialing verification organization; setting
forth an application process; providing for the
confidentiality of information and exceptions; setting forth
legislative rulemaking authority; providing for the
establishment by rule of penalties; and granting immunity to
credentialing entity for reliance upon information provided by
the statewide credentialing verification organization.
Be it enacted by the Legislature of West Virginia:
That §16-1A-1, §16-1A-2, §16-1A-3, §16-1A-4 and §16-1A-5 of
the Code of West Virginia, 1931, as amended, be amended and
reenacted; and that said code be amended by adding thereto five new
sections, designated §16-1A-6, §16-1A-7, §16-1A-8, §16-1A-9 and
§16-1A-10, all to read as follows:
ARTICLE 1A. UNIFORM CREDENTIALING FOR HEALTH CARE PRACTITIONERS.
§16-1A-1. Legislative findings; purpose.
(a) The Legislature finds:
(1) Credentialing, required by hospitals, insurance companies,
prepaid health plans, third party administrators, provider networks and other health care entities, is necessary to assess and verify
the education, training and experience of health care practitioners
to ensure that qualified professionals treat the citizens of this
state.
(2) Although uniform credentialing and recredentialing
application forms have been created to reduce duplication and
increase efficiency, each credentialing entity continues to perform
primary source verification for the practitioners who apply to that
entity for affiliation. Moreover, because credentialing entities
do not follow a common calendar, practitioners are required to
respond to requests throughout the year from various credentialing
entities seeking essentially similar information. This duplication
of primary source verification is time consuming and costly.
(3) The Secretary of the Department of Health and Human
Resources and the Insurance Commissioner share regulatory authority
over the entities requiring credentialing.
(b) The purpose of this article is to continue the advisory
committee previously established to assist in developing a uniform
credentialing process through the development of legislative rules
to govern how a single credentialing verification organization will
operate in this state and, except with respect to health care
facilities, the establishment of a common credentialing calendar.
§16-1A-2. Development of uniform credentialing application forms
and the credentialing process.
Notwithstanding any provision of this code to the contrary, the Secretary of the Department of Health and Human Resources and
the Insurance Commissioner shall jointly propose rules for
legislative approval in accordance with the provisions of article
three, chapter twenty-nine-a of this code governing the development
and use of uniform application forms for credentialing,
recredentialing or updating information of health care
practitioners required to use the forms and the improvement of the
credentialing process, including creation of a credentialing
verification organization and a uniform recredentialing calendar.
§16-1A-3. Definitions.
For the purposes of this article, the following definitions
apply:
(a) "Credentialing" means the process used to assess and
validate the qualifications of a health care practitioner,
including, but not limited to, an evaluation of licensure status,
education, training, experience, competence and professional
judgment.
(b) "Credentialing entity" means any health care facility, as
that term is defined in subsection (j), section two, article two-d
of this chapter, or payor or network that requires credentialing of
health care practitioners.
(c) "Credentialing Verification Organization" means an entity
that performs primary source verification of a health care
practitioner's training, education, experience; "statewide
credentialing verification organization" means the credentialing verification organization selected pursuant to the provisions of
section five of this article.
(d) "Health care practitioner or "practitioner" means a person
required to be credentialed using the uniform forms set forth in the
rule promulgated pursuant to the authority granted in section two,
article one-a of this chapter.
(e) "Insurance Commissioner" or "Commissioner" means the
Insurance Commissioner of the State of West Virginia as set forth
in article two, chapter thirty-three of this code.
(f) "Joint Commission" formerly known as the Joint Commission
on Accreditation of Healthcare Organizations or JCAHO, is a private
sector, United States-based, not-for-profit organization that
operates voluntary accreditation programs for hospitals and other
health care organizations.
(g) "National Committee for Quality Assurance" or "NCQA" is a
private, 501(c)(3) not-for-profit organization that evaluates and
certifies credentialing verification organizations.
(h) "Network" means an organization that represents or
contracts with a defined set of health care practitioners under
contract to provide health care services to a payor's enrollees.
(i) "Payor" means a third party administrator as defined in
section two, article forty-six , chapter thirty-three of this code
and including third party administrators that are required to be
registered pursuant to section thirteen, article forty-six, chapter
thirty-three of this code, any insurance company, health maintenance organization, health care corporation or any other entity required
to be licensed under chapter thirty-three of this code and that, in
return for premiums paid by or on behalf of enrollees, indemnifies
such enrollees or reimburses health care practitioners for medical
or other services provided to enrollees by health care
practitioners.
(j) "Primary source verification procedure" means the procedure
used by a credentialing verification organization to, in accordance
with national committee for quality assurance standards, collect,
verify and maintain the accuracy of documents and other
credentialing information submitted in connection with a health care
practitioner's application to be credentialed.
(k) "Secretary" means the Secretary of the West Virginia
Department of Health and Human Resources as set forth in chapter
sixteen, article one of this code.
(l) "Uniform application form" or "uniform form" means the
blank uniform credentialing or recredentialing form developed and
set forth in a joint procedural rule promulgated pursuant to section
two of this article.
§16-1A-4. Advisory committee.
(a) The Secretary of the Department of Health and Human
Resources and the Insurance Commissioner shall jointly establish an
advisory committee to assist them in the development and
implementation of the uniform credentialing process in this state.
The advisory committee shall consist of fourteen appointed members. Six members shall be appointed by the Secretary of the Department
of Health and Human Resources: One member shall represent a
hospital with one hundred beds or less; one member shall represent
a hospital with more than one hundred beds; one member shall
represent another type of health care facility requiring
credentialing; one member shall be a person currently credentialing
on behalf of health care practitioners; and two of the members shall
represent the health care practitioners subject to credentialing.
Five members shall be representative of the entities regulated by
the Insurance Commissioner that require credentialing and shall be
appointed by the Insurance Commissioner: One member shall represent
an indemnity health care insurer; one member shall represent a
preferred provider organization; one member shall represent a third
party administrator; one member shall represent a health maintenance
organization accredited by URAC; and one member shall represent a
health maintenance organization accredited by the national committee
on quality assurance. The Secretary of the Department of Health and
Human Resources and the Insurance Commissioner, or the designee of
either or both, shall be nonvoting ex officio members. Upon the
effective date of this legislation, the state hospital association,
the state association of licensing boards and state medical
association shall each designate to the department one person to
represent their respective associations and members and those
designees shall be appointed to the advisory committee by the
secretary of the department.
(b) At the expiration of the initial terms, successors will be
appointed to terms of three years. Members may serve an unlimited
number of terms. When a vacancy occurs as a result of the
expiration of a term or otherwise, a successor of like
qualifications shall be appointed. Representatives of the hospital
association, the association of licensing boards and the state
medical association shall serve for three-year terms.
(c) The advisory committee shall meet at least annually to
review the status of uniform credentialing in this state, and may
make further recommendations to the Secretary of the Department of
Health and Human Resources and the Insurance Commissioner as are
necessary to carry out the purposes of this article. Any uniform
forms and the list of health care practitioners required to use the
uniform forms as set forth in legislative rule proposed pursuant to
section two of this article may be amended as needed by procedural
rule.
§16-1A-5. Credentialing Verification Organization.
The Secretary and the Insurance Commissioner shall, with the
advice of the advisory committee, take such steps as are necessary
to select and contract with a credentialing verification
organization that will, beginning no later than July 1, 2015, be the
sole source for primary source verification for all credentialing
entities. The credentialing verification organization selected
shall be responsible for the receipt of all uniform applications,
the primary source verification of the information provided on such applications, and the updating and maintenance of all information
generated by such activities. The dates on which the use of this
statewide credentialing verification organization is mandatory with
respect to the credentialing of the different classes of health care
practitioners shall be determined by emergency and legislative rules
promulgated pursuant to the authority in section ten of this
article.
§16-1A-6. Contract with statewide credentialing verification
organization; requirements.
The Secretary and Insurance Commissioner shall assure that:
(1) Any contract executed with a credentialing verification
organization shall be for an initial contract period of at least
three years, subject to renewals, and the Secretary and Insurance
Commissioner shall, in consultation with the advisory committee,
periodically review the statewide credentialing verification
organization's operations no less often than prior to every renewal.
(2) A credentialing verification organization selected pursuant
to this article must, at a minimum, be certified by the national
committee for quality assurance, be able to demonstrate compliance
with the joint commission's standards for credentialing and with all
federal and state credentialing regulations, and maintain an errors
and omissions insurance policy in amounts deemed to be adequate by
the Secretary and Insurance Commissioner.
(3) Preference shall be given to credentialing verification
organizations organized within the State of West Virginia.
§16-1A-7. Verification process; suspension of requirements.
(a) The statewide credentialing verification organization shall
provide electronic access to the uniform credentialing application
forms developed pursuant to section two of this article.
(b) A health care practitioner seeking to be credentialed must
attest to and submit a completed uniform application form to the
statewide credentialing verification organization and must provide
any additional information requested by such credentialing
verification organization: Provided, That a failure to comply with
a reasonable request for additional information within thirty days
may be grounds for the statewide credentialing verification
organization to submit its report to any credentialing entity with
identification of matters deemed to be incomplete.
(c) Except as provided in subsection (d) of this section, a
credentialing entity may not require a person seeking to be
credentialed or recredentialed to provide verification of any
information contained in the uniform application: Provided, That
nothing in this article is considered to prevent a credentialing
entity from collecting or inquiring about information unavailable
from or through the statewide credentialing verification
organization or from making inquires to the National Practitioner
Data Bank.
(d) A credentialing entity other than a health care facility
must issue a credentialing decision within sixty days after
receiving the statewide credentialing verification organization's completed report and, with respect to affirmative credentialing
decisions, payments pursuant to the contract shall be retroactive
to the date of the decision.
(e) If the statewide credentialing verification organization
fails to maintain national committee for quality assurance
certification or, in the opinion of the Secretary and Insurance
Commissioner, is unable to satisfy compliance with the joint
commission's standards or federal and state credentialing
regulations, the Secretary and Insurance Commissioner may, under
terms and conditions deemed necessary to maintain the integrity of
the credentialing process, notify credentialing entities that the
requirement, relating to the mandatory use of the statewide
credentialing verification organization, is being suspended.
(f) Notwithstanding any other provision of this code,
credentialing entities may contract with the statewide credentialing
verification organization or another credentialing verification
organization to perform credentialing services, such as site visits
to health care practitioners' offices, in addition to those services
for which the statewide credentialing verification organization is
the sole source.
§16-1A-8. Release and uses of information collected;
confidentiality.
(a) Upon execution of a release by the health care
practitioner, the statewide credentialing verification organization
shall, under terms established in rule, provide the credentialing entity with electronic access to data generated.
(b) In order to assure that information in its files is
current, the statewide credentialing verification organization shall
establish processes to update information as required by
credentialing entities.
(c) Except as provided in subsection (d) of this section, all
information collected by the statewide credentialing verification
organization from any source is confidential in nature, is exempt
from disclosure pursuant to subpoena or discovery, is exempt from
disclosure under the provisions of article one, chapter twenty-
nine-b of this code, and shall be used solely by a credentialing
entity to review the professional background, competency and
qualifications of each health care practitioner applying to be
credentialed.
(d) Credentialing information received by a credentialing
entity from the statewide credentialing verification organization
shall not be disclosed except:
(1) In appeals of credentialing decisions or to peer review and
quality improvement committees: Provided, That such information
shall be afforded the same protection from disclosure as is provided
to other records used in proceedings subject to section three,
article three-c, chapter thirty of this code;
(2) In any matter in which an action or order of a professional
licensing board or other state or federal regulatory authority is
at issue, including any proceeding brought by or on behalf of a health care practitioner or patient or by a regulatory body that
challenges the actions, omissions or conduct of a credentialing
entity with respect to credentialing decision; or
(3) When authorized by the health care practitioner to whom the
credentialing information relates: Provided, That the health care
practitioner's authorization shall only permit disclosure of
information that he or she provided directly to the statewide
credentialing verification organization.
(e) Upon the expiration of the contract with a statewide
credentialing verification organization, all information collected
in connection with the duties under such contract shall be delivered
to the Secretary and Insurance Commissioner to the extent allowed
by law and subject to any legal requirements applicable to the
sources of such information.
(f) The statewide credentialing verification organization may
enter into contractual agreements to define the data type and form
of information to be provided to users and to give users assurances
of the integrity of the information collected.
§16-1A-9. Rulemaking; fees; penalties.
The Secretary and Insurance Commissioner, in consultation with
the advisory committee, shall propose rules for legislative approval
in accordance with the provisions of article three, chapter twenty-
nine-a of this code on or before June 1, 2011. The legislative
rules must include, but shall not be limited to, the following
matters:
(1) Performance standards for the evaluation of the statewide
credentialing verification organization;
(2) The manner in which the statewide credentialing
verification organization must demonstrate compliance with
credentialing standards and regulations;
(3) Penalties, including monetary sanctions, for violations of
any provisions of this article;
(4) Duties of the statewide credentialing verification
organization and the timelines for completion of its verification
duties and services;
(5) Procedures for maintaining healthcare practitioner files;
(6) The payment system to cover the costs of the credentialing
program;
(7) The use and confidentiality of data generated, collected
and maintained by the statewide credentialing verification
organization;
(8) Except with respect to health care facilities, the
methodology for determination and communication of the common
recredentialing date for a practitioner; and
(9) Procedures and criteria for the bidding and selection of
the statewide credentialing verification organization.
§16-1A-10. Immunity.
(a) If the statewide credentialing verification organization
certifies that information in an application has been verified
according to its primary source verification procedures, any negligence by the statewide credentialing verification organization
in its collection and verification of such information may not be
imputed to a credentialing entity that receives such information
and, further, such credentialing entity is not liable for damages
arising from its reliance on such information in its credentialing
process unless the credentialing entity knew or should have known
such information was incorrect: Provided, That a credentialing
entity is otherwise liable as provided by law for damages arising
from its credentialing decisions.
(b) This article may not be interpreted as requiring a
credentialing entity as defined in this article, to grant medical
staff appointment to any practitioner nor may it be interpreted as
requiring a credentialing entity to permit any practitioner to
provide patient care or as requiring a payor or network to reimburse
a practitioner for services.