Subchapter III. Uniform Credentialing Forms.
§ 31–3251. Definitions.
For the purposes of this subchapter, the term:
(1) “Commissioner” means Commissioner of the Department of Insurance and Securities Regulation.
(2) “Credentialing intermediary” means a person to whom a health insurer has delegated credentialing or recredentialing authority and responsibility.
(3) “Health benefit plan” means any accident and health insurance policy or certificate, hospital and medical services corporation contract, health maintenance organization subscriber contract, plan provided by a multiple employer welfare arrangement, or plan provided by another benefit arrangement. The term “health benefit plan” does not mean accident only, credit, or disability insurance; coverage of Medicare services or federal employee health plans, pursuant to contracts with the United States government; Medicare supplemental or long-term care insurance; dental only or vision only insurance; specified disease insurance; hospital confinement indemnity coverage; limited benefit health coverage; coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law; automobile medical payment insurance; medical expense and loss of income benefits; or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.
(4) “Health care provider” means:
(A) An individual who is licensed, certified, or otherwise authorized to provide health care services by the District of Columbia for a practice set forth under § 3-1201.02; or
(B) An agency, organization, facility, or distinct part of any of them, licensed under subchapter I of Chapter 5 of Title 44.
(5) “Health insurer” means any person that provides one or more health benefit plans or insurance in the District of Columbia, including an insurer, a hospital and medical services corporation, a fraternal benefit society, a health maintenance organization, a multiple employer welfare arrangement, or any other person providing a plan of health insurance subject to the authority of the Commissioner.
(6) “Provider panel” means providers that contract with a health insurer to provide health care services to the enrollees under a health benefit plan of the health insurer.
(7) “Uniform credentialing form” means the form designed by the Commissioner, by regulation, for use by a health insurer or its credentialing intermediary for credentialing and re-credentialing of a health care provider for participation on a provider panel.
§ 31–3252. Application for becoming credentialed.
(a) A health insurer or its credentialing intermediary shall accept the uniform credentialing form as the sole application for a health care provider to become credentialed or recredentialed for a provider panel of the health insurer.
(b) A health insurer or its credentialing intermediary shall make the uniform credentialing form available to any health care provider that is to be credentialed or re-credentialed by the health insurer or credentialing intermediary.
§ 31–3253. Penalties.
The Commissioner may impose a penalty not to exceed $500 against any health insurer for each violation of this subchapter by the health insurer or its credentialing intermediary.
§ 31–3254. Regulations.
The Commissioner shall promulgate rules and regulations to implement the provisions of this subchapter.
§ 31–3255. Applicability.
This subchapter shall apply, 120 days after the promulgation of the final regulations pursuant to § 31-3254, to health insurers, as defined in § 31-3251(5), and any agency, organization, facility, or distinct part thereof, licensed pursuant to subchapter I of Chapter 5 of Title 44.
