Health care provider credentialing.
AB 2457
California Bills
20250AB__245799INT INTRODUCED 2026-02-20 2025 AB INT Introduced by Assembly Member Connolly LEAD_AUTHOR ASSEMBLY Connolly
An act to amend Sections 1374.198 and 1380.2 of the Health and Safety Code, relating to health care. health care Health care provider credentialing. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law requires a full service health care service plan, excluding a Medi-Cal managed care plan, or its delegate, to subscribe to and use the Council for Affordable Quality Healthcare credentialing form on and after January 1, 2028.
On and after January 1, 2027, existing law requires a health care service plan, excluding a Medi-Cal managed care plan, or its delegate, that credentials health care providers for its networks to make a determination regarding the credentials of a provider within days after receiving a completed provider credentialing application. This bill would extend the application of the above-described requirements to Medi-Cal managed care plans. Because a willful violation of these requirements by a Medi-Cal managed care plan would be a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason. MAJORITY NO YES YES NO NO NO NO NO NO NO The people of the State of California do enact as follows:
SECTION
Section 1374.198 of the Health and Safety Code is amended to read: 1374.198. "?>Except as provided in
Section 1374.197, within one year of the operative date of this section, a health care service plan, including a Medi-Cal managed care plan, or its delegate that credentials health care providers for its networks shall make a determination regarding the credentials of a health care provider within days after receiving a completed provider credentialing application, including all required third-party verifications.
Upon receipt of the application by the credentialing department, the health care service plan or its delegate shall notify the applicant within business days to verify receipt and inform the applicant whether the application is complete. The health care service plan shall activate the provider upon successful approval and notify the applicant of the activation within days of approval if the approval occurs prior to the end of the 90-day timeline. The 90-day timeline shall apply only to the credentialing process and does not include contracting completion.
If the health care service plan or its delegate does not meet the 90-day requirement, the applicant’s credentials shall be provisionally approved for days unless any of the following apply: (1)</xhtml:p>"?> (
a) The applicant is subject to discipline by the licensing entity for that applicant. (2)</xhtml:p>"?> (
b) The applicant has one or more adverse action reports or one or more reports of malpractice payments filed with the National Practitioner Data Bank. (3)</xhtml:p>"?> (
c) The applicant has not been credentialed by the health care service plan in the past five years. (b)<xhtml:span class="EnSpace"/>This
section does not apply to contracts with the State Department of Health Care Services pursuant to
Chapter 7 (commencing with
Section 14000) or
Chapter 8 (commencing with
Section 14200) of Part of Division of Welfare and Institutions Code.</xhtml:p>"?>
SEC.
Section 1380.2 of the Health and Safety Code is amended to read: 1380.2. (a) "?>Notwithstanding any other law, except as provided in
Section 1374.197, on and after January 1, 2028, a full service health care service plan, including a Medi-Cal managed care plan, or its delegate shall subscribe to and use the most recent version of the Council for Affordable Quality Healthcare (CAQH) credentialing form, and shall comply with the CAQH credentialing processes. (2)</xhtml:p>"?> (
b) A full service health care service plan or its delegate shall only request additional information from a provider to clarify and confirm information that is provided on the CAQH credentialing form, including verification of information not specifically disclosed on the provider’s application. The provider shall respond to the request within business days. A health care service plan or its delegate shall minimize the number of requests for additional information from providers. A provider shall submit their credentialing form and maintain their credentialing information in the CAQH database in a manner consistent with CAQH standards. (b)<xhtml:span class="EnSpace"/>This
section does not apply to contracts with the State Department of Health Care Services pursuant to
Chapter 7 (commencing with
Section 14000) or
Chapter 8 (commencing with
Section 14200) of Part of Division of the Welfare and Institutions Code.</xhtml:p>"?>
SEC. 3. No reimbursement is required by this act pursuant to
Section of
Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of