Credentialing of healthcare providers by insurers and HMOs

Bulletin 132 CREDENTIALING OF HEALTH CARE PROVIDERS BY INSURERS AND HEALTH MAINTENANCE ORGANIZATIONS July 1, 2005 This Bulletin is directed to all insurers and health maintenance organizations (HMO) doing business in the state of Indiana. “Credentialing” is defined at IC 27-8-11-1(b) as a process through which an insurer makes a determination, based upon criteria established by the insurer or HMO, concerning whether a provider is eligible to provide health care services to an insured or enrollee, and receive reimbursement for those services, under a contract entered into between the provider and the insurer or HMO. Currently, not all insurers and HMOs use the same credentialing application form. The General Assembly reviewed the issue and determined that it would improve the system of credentialing if all insurers and HMOs used a standard application form. Senate Enrolled Act 43 (Pub. Law 26, 2005) directs the Department of Insurance to prescribe the application form developed by the Council for Affordable Quality Healthcare as a standardized form for credentialing. Therefore, pursuant to Senate Enrolled Act 43 (Pub. Law 26-2005), the Department of Insurance hereby prescribes the credentialing application form used by the Council for Affordable Quality Healthcare to be used by all insurers and HMOs doing business in the state of Indiana. The application may be used in either an electronic or paper format. Insurers and HMOs may choose to have the CAQH provide credentialing services or they can perform the function themselves. The CAQH form is available on the Department of Insurance website at http://www.in.gov/idoi/2347.htm. INDIANA DEPARTMENT OF INSURANCE James Atterholt, Commissioner