Provisional Credentialing Laws: Practicing While the Plan Decides

Credentialing takes time, and while it runs, a new clinician often cannot be paid as in network. Most states leave that wait entirely to the plan. A few have written laws that let a provider practice, or be paid, while the plan decides, or that treat the provider as participating if the plan misses a deadline. These laws are narrow, and each has conditions that decide whether you qualify. Read them closely before relying on one.

What does New York's provisional credentialing require?

New York's rule is the most detailed. Under N.Y. Ins. Law 4803(a)(2), a professional is "deemed provisionally credentialed" when all of these are true:

• the professional is newly licensed, or "has recently relocated to this state from another state and has not previously practiced in this state";
• he or she joins "a group practice of health care professionals each of whom participates in the in-network portion of an insurer's network";
• the completed application is "neither approved nor declined within sixty days of submission"; and
• the group notifies the insurer in writing that, if the application is ultimately denied, the professional or group will refund in-network payments above any out-of-network benefits and will not bill the patient beyond normal cost sharing.

Participation begins "on the day following the sixtieth day of receipt of the completed application" and lasts until the insurer decides. A provisionally credentialed physician cannot be designated as a member's primary care physician until fully credentialed. A separate paragraph, 4803(a)(3), covers newly licensed or relocated physicians, and physicians whose new corporate relationship produces a new tax ID, who join a participating hospital, diagnostic and treatment center or certain mental hygiene facilities. See New York's credentialing deadlines.

How does North Carolina's temporary credential work?

If an insurer has not approved or denied a completed credentialing application within 60 days, then "upon receipt of a written request from the applicant and within five business days of its receipt, the insurer shall issue a temporary credential," provided the applicant has a valid North Carolina license for the services involved (N.C. Gen. Stat. 58-3-230(a)). The temporary credential lasts until the application is approved or denied.

Two limits matter. The insurer "shall not issue a temporary credential if the applicant has reported on the application a history of medical malpractice claims, a history of substance abuse or mental health issues, or a history of Medical Board disciplinary action." And the credential is not automatic: the applicant has to ask in writing. See North Carolina's credentialing deadlines.

What is Colorado's deemed participation rule?

Colorado's 2021 law on timely credentialing of physicians (SB21-126) requires a carrier to send a receipt within 7 calendar days after receiving an application. According to the General Assembly's summary of the act as enacted, if a carrier "receives an application but fails to provide the applicant a receipt within 7 calendar days, the carrier shall consider the applicant a participating physician, effective no later than 53 calendar days following the carrier's receipt of the application." The same law sets a 60-day deadline to conclude credentialing of a completed application. The rule is aimed at physicians and turns on a missed receipt, so keep proof of the date you applied and of any receipt you got. See Colorado's credentialing deadlines.

Does Texas pay providers during credentialing?

For physicians joining an established, contracted medical group, yes. A physician licensed by and in good standing with the Texas Medical Board who submits the plan's required credentialing information and agrees to the group's contract terms must be treated, "for payment purposes only," as a participating provider while credentialing runs (Tex. Ins. Code 1452.103 and 1452.104). If the plan later denies credentialing, it may recover the difference between in-network and out-of-network payment from the physician or group, and the member is held harmless (1452.106 and 1452.107). See joining a participating group.

Does Virginia pay for care during a pending application?

In a limited way. Virginia requires carriers that credential providers to approve or deny a completed application within 60 days and, once a new applicant is "credentialed and contracted," to pay claims for services rendered while the application was pending "at the in-network rate" (Va. Code 38.2-3407.10:1(B)). The rule applies "only if a contractual relationship exists between the carrier and the new provider applicant or entity for whom the new provider applicant is employed or engaged," so it helps clinicians joining contracted practices, not providers facing a closed panel. It has a catch: if credentialing is denied, the applicant may not collect anything from the patient for the pending period, and the applicant must give patients advance written notice before treating them under the rule (38.2-3407.10:1(F) and (G)).

What changes in California in 2027?

California has a credentialing timeline taking effect January 1, 2027. We could not open the statute text from our research server, so the following is as described in UnitedHealthcare's State and Federal Regulatory Addendum (rev. September 2026), which cites Cal. Health and Safety Code 1374.198 and Insurance Code 10144.565: a plan must decide within 90 days of a completed application, including third-party verifications, and if it does not, the applicant's credentials "shall be provisionally approved for 120 days" unless the applicant is subject to licensing discipline, has adverse action or malpractice payment reports in the National Practitioner Data Bank, or another listed exception applies. The 90 days covers credentialing only and "does not include contracting completion." The chaptered bill (AB 1041, Stats. 2025, ch. 630) also withholds provisional approval from an applicant "not credentialed by the health care service plan in the past five years," which on its face leaves out first-time applicants; ask a California healthcare attorney how it applies to you. Confirm the statute before relying on it. See California's 2027 credentialing law.

Do plans offer provisional credentialing on their own?

Some do, by policy rather than law. CMS's manual for Medicare Advantage plans lets a plan adopt a policy permitting "initial credentialing for a period of up to 60 days" for a newly trained professional who completed training in the last 12 months, if the plan verifies the license and five years of malpractice settlements and the credentialing committee approves (Medicare Managed Care Manual, Chapter 6, section 60.3). A Louisiana Medicaid plan's policy allows provisional credentialing once, for first-time applicants, for no longer than 60 calendar days (Louisiana Healthcare Connections, LA.CRED.01). Ask your plan whether it has a provisional option.

What do these laws not do?

None of them gives a right to a contract. They speed up or bridge credentialing; they do not open a closed network. A provider whose application was refused because the panel is closed usually never reaches the credentialing clock these laws regulate. They also apply only to plans regulated by that state, which leaves out self-funded employer plans. See self-funded employer plans and network access.

How do you use one?

1. Make the application complete and document the date the plan received it. Every clock starts at completion.
2. Confirm you meet the conditions (newly licensed or relocated, joining a participating group, no reported history that disqualifies you).
3. Make the written request or notice the law requires, such as North Carolina's request or New York's group refund notice.
4. If the plan does not comply, send a short letter citing the statute and asking for written confirmation of your status. If that fails, a complaint to the state insurance department is appropriate, because a missed statutory deadline is squarely within its authority. See complaining to the state insurance department.

We prepare those letters and complaint drafts for you to sign and send as part of a Payer Network Dispute ($799 per payer). We are not a law firm and do not give legal advice; if you need an opinion on whether a statute applies to you, ask a healthcare attorney.