2026 -- H 8310

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LC006085

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2026

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A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES --

HEALTHCARE PROVIDER CREDENTIALING

     Introduced By: Representatives Place, Hopkins, Santucci, Kislak, McNamara, Cotter,
Shanley, Stewart, Noret, and Knight

     Date Introduced: March 18, 2026

     Referred To: House Health & Human Services

     It is enacted by the General Assembly as follows:

     SECTION 1. Section 27-18-83 of the General Laws in Chapter 27-18 entitled "Accident

and Sickness Insurance Policies" is hereby amended to read as follows:

     27-18-83. Healthcare provider credentialing.

     (a) For applications received on or after January 1, 2018, a healthcare entity or health plan

operating in the state shall be required to issue a decision regarding the credentialing of a healthcare

provider as soon as practicable, but no later than forty-five (45) thirty (30) calendar days after the

date of receipt of a complete credentialing application. For any provider already credentialed with

Medicare, the timeline shall be ten (10) business days.

     (b) For minor changes to the demographic information of an individual healthcare provider

who is already credentialed with a particular healthcare entity or health plan, such healthcare entity

or health plan shall complete such change within seven (7) five (5) business days of receipt of the

healthcare provider’s request. Minor changes to demographic information requested by individual

providers shall be submitted in the timeframe, and manner required by the healthcare entity or

health plan, and shall include all supporting documentation required by the particular healthcare

entity or health plan. For purposes of this section, minor changes to the information profile of a

healthcare provider shall include, but not be limited to, changes of address and changes to a

healthcare provider’s tax identification number.

     (c) Each healthcare entity or health plan shall establish a written standard defining what

elements constitute a complete credentialing application and shall distribute this standard with the

written version of the credentialing application and make such standard available on the healthcare

entity’s or health plan’s website. If the payer fails to meet the timeline in subsection (a) of this

section, the provider shall be deemed provisionally credentialed, and the payer shall reimburse the

provider retroactively for all covered services rendered from the date the completed application

was received.

     (d) Each healthcare entity or health plan shall respond to inquiries by the applicant

regarding the status of an application.

     (1) Each healthcare entity or health plan shall provide the applicant with automated

application status updates, at least once every fifteen (15) calendar days, informing the applicant of

any missing application materials until the application is deemed complete;

     (2) Each healthcare entity or health plan shall inform the applicant within five (5) business

days that the credentialing application is complete; and

     (3) If the healthcare entity or health plan denies a credentialing application, the healthcare

entity or health plan shall notify the healthcare provider in writing and shall provide the healthcare

provider with any and all reasons for denying the credentialing application.

     (e) The effective date for billing privileges for healthcare providers under a particular

healthcare entity or health plan shall be the next business day following the date of approval of the

credentialing application.

     (f) For applications received from resident graduates on or after January 1, 2018, a

healthcare entity or health plan shall offer a transitional or conditional approval process such that a

resident graduate who has submitted an otherwise complete application and met all other criteria,

may be conditionally approved, effective upon successful graduation from the training program.

     (g) For the purposes of this section, the following definitions apply:

     (1) “Complete credentialing application” means all the requested material has been

submitted.

     (2) “Date of receipt” means the date the healthcare entity or health plan receives the

completed credentialing application whether via electronic submission or as a paper application.

     (3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or

medical or dental service corporation or plan or health maintenance organization, or a contractor

as defined in § 23-17.13-2 [repealed] that operates a health plan.

     (4) “Healthcare provider” means a healthcare professional.

     (5) “Health plan” means a plan operated by a healthcare entity that provides for the delivery

of healthcare services to persons enrolled in those plans through:

LC006085 - Page 2 of 9

     (i) Arrangements with selected providers to furnish healthcare services; and

     (ii) Financial incentives for persons enrolled in the plan to use the participating providers

and procedures provided for by the health plan.

     (h) The office of the health insurance commissioner shall enforce the provisions of this

chapter and may impose administrative penalties consistent with its existing authority under title

27. Non-compliant contract provisions are void. The commissioner shall adopt rules and

regulations to implement this chapter and shall require payers to submit quarterly reports on

credentialing timelines.

     SECTION 2. Section 27-19-74 of the General Laws in Chapter 27-19 entitled "Nonprofit

Hospital Service Corporations" is hereby amended to read as follows:

     27-19-74. Healthcare provider credentialing.

     (a) For applications received on or after January 1, 2018, a healthcare entity or health plan

operating in the state shall be required to issue a decision regarding the credentialing of a healthcare

provider as soon as practicable, but no later than forty-five (45) thirty (30) calendar days after the

date of receipt of a complete credentialing application. For any provider already credentialed with

Medicare, the timeline shall be ten (10) business days.

     (b) For minor changes to the demographic information of an individual healthcare provider

who is already credentialed with a particular healthcare entity or health plan, such healthcare entity

or health plan shall complete such change within seven (7) five (5) business days of receipt of the

healthcare provider’s request. Minor changes to demographic information requested by individual

providers shall be submitted in the timeframe, and manner required by the healthcare entity or

health plan, and shall include all supporting documentation required by the particular healthcare

entity or health plan. For purposes of this section, minor changes to the information profile of a

healthcare provider shall include, but not be limited to, changes of address and changes to a

healthcare provider’s tax identification number.

     (c) Each healthcare entity or health plan shall establish a written standard defining what

elements constitute a complete credentialing application and shall distribute this standard with the

written version of the credentialing application and make such standard available on the healthcare

entity’s or health plan’s website. If the payer fails to meet the timeline in subsection (a) of this

section, the provider shall be deemed provisionally credentialed, and the payer shall reimburse the

provider retroactively for all covered services rendered from the date the completed application

was received.

     (d) Each healthcare entity or health plan shall respond to inquiries by the applicant

regarding the status of an application.

LC006085 - Page 3 of 9

     (1) Each healthcare entity or health plan shall provide the applicant with automated

application status updates, at least once every fifteen (15) calendar days, informing the applicant of

any missing application materials until the application is deemed complete;

     (2) Each healthcare entity or health plan shall inform the applicant within five (5) business

days that the credentialing application is complete; and

     (3) If the healthcare entity or health plan denies a credentialing application, the healthcare

entity or health plan shall notify the healthcare provider in writing and shall provide the healthcare

provider with any and all reasons for denying the credentialing application.

     (e) The effective date for billing privileges for healthcare providers under a particular

healthcare entity or health plan shall be the next business day following the date of approval of the

credentialing application.

     (f) For applications received from resident graduates on or after January 1, 2018, a

healthcare entity or health plan shall offer a transitional or conditional approval process such that a

resident graduate who has submitted an otherwise complete application and met all other criteria,

may be conditionally approved, effective upon successful graduation from the training program.

     (g) For the purposes of this section, the following definitions apply:

     (1) “Complete credentialing application” means all the requested material has been

submitted.

     (2) “Date of receipt” means the date the healthcare entity or health plan receives the

completed credentialing application whether via electronic submission or as a paper application.

     (3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or

medical or dental service corporation or plan or health maintenance organization, or a contractor

as defined in § 23-17.13-2 [repealed] that operates a health plan.

     (4) “Healthcare provider” means a healthcare professional.

     (5) “Health plan” means a plan operated by a healthcare entity that provides for the delivery

of healthcare services to persons enrolled in those plans through:

     (i) Arrangements with selected providers to furnish healthcare services; and

     (ii) Financial incentives for persons enrolled in the plan to use the participating providers

and procedures provided for by the health plan.

     (h) The office of the health insurance commissioner shall enforce the provisions of this

chapter and may impose administrative penalties consistent with its existing authority under title

27. Non-compliant contract provisions are void. The commissioner shall adopt rules and

regulations to implement this chapter and shall require payers to submit quarterly reports on

credentialing timelines.

LC006085 - Page 4 of 9

     SECTION 3. Section 27-20-70 of the General Laws in Chapter 27-20 entitled "Nonprofit

Medical Service Corporations" is hereby amended to read as follows:

     27-20-70. Healthcare provider credentialing.

     (a) For applications received on or after January 1, 2018, a healthcare entity or health plan

operating in the state shall be required to issue a decision regarding the credentialing of a healthcare

provider as soon as practicable, but no later than forty-five (45) thirty (30) calendar days after the

date of receipt of a complete credentialing application. For any provider already credentialed with

Medicare, the timeline shall be ten (10) business days.

     (b) For minor changes to the demographic information of an individual healthcare provider

who is already credentialed with a particular healthcare entity or health plan, the healthcare entity

or health plan shall complete the change within seven (7) five (5) business days of receipt of the

healthcare provider’s request. Minor changes to demographic information requested by individual

providers shall be submitted in the timeframe, and manner required by the healthcare entity or

health plan, and shall include all supporting documentation required by the particular healthcare

entity or health plan. For purposes of this section, minor changes to the information profile of a

healthcare provider shall include, but not be limited to, changes of address and changes to a

healthcare provider’s tax identification number.

     (c) Each healthcare entity or health plan shall establish a written standard defining what

elements constitute a complete credentialing application and shall distribute this standard with the

written version of the credentialing application and make the standard available on the healthcare

entity’s or health plan’s website. If the payer fails to meet the timeline in subsection (a) of this

section, the provider shall be deemed provisionally credentialed, and the payer shall reimburse the

provider retroactively for all covered services rendered from the date the completed application

was received.

     (d) Each healthcare entity or health plan shall respond to inquiries by the applicant

regarding the status of an application.

     (1) Each healthcare entity or health plan shall provide the applicant with automated

application status updates, at least once every fifteen (15) calendar days, informing the applicant of

any missing application materials until the application is deemed complete;

     (2) Each healthcare entity or health plan shall inform the applicant within five (5) business

days that the credentialing application is complete; and

     (3) If the healthcare entity or health plan denies a credentialing application, the healthcare

entity or health plan shall notify the healthcare provider in writing and shall provide the healthcare

provider with any and all reasons for denying the credentialing application.

LC006085 - Page 5 of 9

     (e) The effective date for billing privileges for healthcare providers under a particular

healthcare entity or health plan shall be the next business day following the date of approval of the

credentialing application.

     (f) For applications received from resident graduates on or after January 1, 2018, a

healthcare entity or health plan shall offer a transitional or conditional approval process such that a

resident graduate who has submitted an otherwise complete application and met all other criteria,

may be conditionally approved, effective upon successful graduation from the training program.

     (g) For the purposes of this section, the following definitions apply:

     (1) “Complete credentialing application” means all the requested material has been

submitted.

     (2) “Date of receipt” means the date the healthcare entity or health plan receives the

completed credentialing application whether via electronic submission or as a paper application.

     (3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or

medical or dental service corporation or plan or health maintenance organization, or a contractor

as defined in § 23-17.13-2 [repealed] that operates a health plan.

     (4) “Healthcare provider” means a healthcare professional.

     (5) “Health plan” means a plan operated by a healthcare entity that provides for the delivery

of healthcare services to persons enrolled in those plans through:

     (i) Arrangements with selected providers to furnish healthcare services; and

     (ii) Financial incentives for persons enrolled in the plan to use the participating providers

and procedures provided for by the health plan.

     (h) The office of the health insurance commissioner shall enforce the provisions of this

chapter and may impose administrative penalties consistent with its existing authority under title

27. Non-compliant contract provisions are void. The commissioner shall adopt rules and

regulations to implement this chapter and shall require payers to submit quarterly reports on

credentialing timelines.

     SECTION 4. Section 27-41-87 of the General Laws in Chapter 27-41 entitled "Health

Maintenance Organizations" is hereby amended to read as follows:

     27-41-87. Healthcare provider credentialing.

     (a) For applications received on or after January 1, 2018, a healthcare entity or health plan

operating in the state shall be required to issue a decision regarding the credentialing of a healthcare

provider as soon as practicable, but no later than forty-five (45) thirty (30) calendar days after the

date of receipt of a complete credentialing application. For any provider already credentialed with

Medicare, the timeline shall be ten (10) business days.

LC006085 - Page 6 of 9

     (b) For minor changes to the demographic information of an individual healthcare provider

who is already credentialed with a particular healthcare entity or health plan, the healthcare entity

or health plan shall complete the change within seven (7) five (5) business days of receipt of the

healthcare provider’s request. Minor changes to demographic information requested by individual

providers shall be submitted in the time frame, and manner required by the healthcare entity or

health plan, and shall include all supporting documentation required by the particular healthcare

entity or health plan. For purposes of this section, minor changes to the information profile of a

healthcare provider shall include, but not be limited to, changes of address and changes to a

healthcare provider’s tax identification number.

     (c) Each healthcare entity or health plan shall establish a written standard defining what

elements constitute a complete credentialing application and shall distribute this standard with the

written version of the credentialing application and make the standard available on the healthcare

entity’s or health plan’s website. If the payer fails to meet the timeline in subsection (a) of this

section, the provider shall be deemed provisionally credentialed, and the payer shall reimburse the

provider retroactively for all covered services rendered from the date the completed application

was received.

     (d) Each healthcare entity or health plan shall respond to inquiries by the applicant

regarding the status of an application.

     (1) Each healthcare entity or health plan shall provide the applicant with automated

application status updates, at least once every fifteen (15) calendar days, informing the applicant of

any missing application materials until the application is deemed complete;

     (2) Each healthcare entity or health plan shall inform the applicant within five (5) business

days that the credentialing application is complete; and

     (3) If the healthcare entity or health plan denies a credentialing application, the healthcare

entity or health plan shall notify the healthcare provider in writing and shall provide the healthcare

provider with any and all reasons for denying the credentialing application.

     (e) The effective date for billing privileges for healthcare providers under a particular

healthcare entity or health plan shall be the next business day following the date of approval of the

credentialing application.

     (f) For applications received from resident graduates on or after January 1, 2018, a

healthcare entity or health plan shall offer a transitional or conditional approval process such that a

resident graduate who has submitted an otherwise complete application and met all other criteria,

may be conditionally approved, effective upon successful graduation from the training program.

     (g) For the purposes of this section, the following definitions apply:

LC006085 - Page 7 of 9

     (1) “Complete credentialing application” means all the requested material has been

submitted.

     (2) “Date of receipt” means the date the healthcare entity or health plan receives the

completed credentialing application whether via electronic submission or as a paper application.

     (3) “Healthcare entity” means a licensed insurance company or nonprofit hospital or

medical or dental service corporation or plan or health maintenance organization, or a contractor

as defined in § 23-17.13-2 [repealed] that operates a health plan.

     (4) “Healthcare provider” means a healthcare professional.

     (5) “Health plan” means a plan operated by a healthcare entity that provides for the delivery

of healthcare services to persons enrolled in those plans through:

     (i) Arrangements with selected providers to furnish healthcare services; and

     (ii) Financial incentives for persons enrolled in the plan to use the participating providers

and procedures provided for by the health plan.

     (h) The office of the health insurance commissioner shall enforce the provisions of this

chapter and may impose administrative penalties consistent with its existing authority under title

27. Non-compliant contract provisions are void. The commissioner shall adopt rules and

regulations to implement this chapter and shall require payers to submit quarterly reports on

credentialing timelines.

     SECTION 5. This act shall take effect upon passage.

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LC006085

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES --

HEALTHCARE PROVIDER CREDENTIALING

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     This act would amend the timelines related to healthcare provider credentialing.

     This act would take effect upon passage.

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LC006085

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LC006085 - Page 9 of 9