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Iowa Retrospective Credentialing Legislation Effective in July

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The Iowa Insurance Division (IID) has adopted a rule that implements 2008 legislation requiring health plans to retrospectively pay clean claims of physicians for covered medical services provided during the credentialing period. The rule becomes effective July 22, 2009.

The credentialing period begins on the “application date” when the health insurer receives the physician’s complete credentialing application and ends on the date of final determination approving the application.

The rule applies only to Allopathic Physicians (M.D.) or Osteopathic Physicians (D.O.) with a primary or alternate practice location in the Iowa who are being initially credentialed. It does not apply to physician assistants, advanced nurse practitioners, mental health practitioners or any other allied health practitioner, or to physicians who are currently participating in the network.

The date the application is complete will be assigned as the network effective date. "Complete" refers to all required information, documentation and explanations. If the missing information is not received in 30 days, the application is considered withdrawn and will be returned to the provider. The rule stipulates that providers may not submit claims until the credentialing process is complete.

Provider file downloads to the Midlands Choice payers are transmitted the week following the monthly Membership Credentials Committee meeting, which meets the second Wednesday of each month. Payers who receive provider download files may see retroactive effective dates on these downloads for newly credentialed providers.

We will also look for claims that may have been submitted and repriced as non-participating if the provider failed to hold claims.  Claims submitted before credentialing is final will be re-priced as in-network and forwarded as corrected claims.

Text Published by Iowa Insurance Division