§ 4803. Health care professional applications and terminations. (a)\n(1) An insurer which offers a managed care product shall, upon request,\nmake available and disclose to health care professionals written\napplication procedures and minimum qualification requirements which a\nhealth care professional must meet in order to be considered by the\ninsurer for participation in the in-network benefits portion of the\ninsurer's network for the managed care product. The insurer shall\nconsult with appropriately qualified health care professionals in\ndeveloping its qualification requirements for participation in the\nin-network benefits portion of the insurer's network for the managed\ncare product. An insurer shall complete review of the health care\nprofessional's application to participate in the in-network portion of\nthe insurer's network and, within sixty days of receiving a health care\nprofessional's completed application to participate in the insurer's\nnetwork, will notify the health care professional as to: (A) whether he\nor she is credentialed; or (B) whether additional time is necessary to\nmake a determination because of a failure of a third party to provide\nnecessary documentation. In such instances where additional time is\nnecessary because of a lack of necessary documentation, an insurer shall\nmake every effort to obtain such information as soon as possible and\nshall make a final determination within twenty-one days of receiving the\nnecessary documentation.\n (2) If the completed application of a newly-licensed health care\nprofessional or a health care professional who has recently relocated to\nthis state from another state and has not previously practiced in this\nstate, who joins a group practice of health care professionals each of\nwhom participates in the in-network portion of an insurer's network, is\nneither approved nor declined within sixty days of submission of a\ncompleted application pursuant to paragraph one of this subsection, such\nhealth care professional shall be deemed "provisionally credentialed"\nand may participate in the in-network portion of an insurer's network;\nprovided, however, that a provisionally credentialed physician may not\nbe designated as an insured's primary care physician until such time as\nthe physician has been fully credentialed. The network participation for\na provisionally credentialed health care professional shall begin on the\nday following the sixtieth day of receipt of the completed application\nand shall last until the final credentialing determination is made by\nthe insurer. A health care professional shall only be eligible for\nprovisional credentialing if the group practice of health care\nprofessionals notifies the insurer in writing that, should the\napplication ultimately be denied, the health care professional or the\ngroup practice: (A) shall refund any payments made by the insurer for\nin-network services provided by the provisionally credentialed health\ncare professional that exceed any out-of-network benefits payable under\nthe insured's contract with the insurer; and (B) shall not pursue\nreimbursement from the insured, except to collect the copayment or\ncoinsurance that otherwise would have been payable had the insured\nreceived services from a health care professional participating in the\nin-network portion of an insurer's network. Interest and penalties\npursuant to section three thousand two hundred twenty-four-a of this\nchapter shall not be assessed based on the denial of a claim submitted\nduring the period when the health care professional was provisionally\ncredentialed; provided, however, that nothing herein shall prevent an\ninsurer from paying a claim from a health care professional who is\nprovisionally credentialed upon submission of such claim. An insurer\nshall not deny, after appeal, a claim for services provided by a\nprovisionally credentialed health care professional solely on the ground\nthat the claim was not timely fi
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