§ 20-3456 – Covered services; claims
20-3456. Covered services; claims A health insurer may not deny a claim for a covered service provided to a subscriber by a participating provider who has a fully executed contract with a network plan if the covered services are provided after the date of approval of the credentialing application.
§ 20-3457 – Availability of credentialing information; policies
20-3457. Availability of credentialing information; policies A. A health insurer shall make the following nonproprietary information available to all applicants for credentialing and shall post the information on its website: 1. The applicable credentialing policies and procedures. 2. A list of all the information required to be included in an application. 3. A checklist of […]
§ 20-3458 – Recredentialing
20-3458. Recredentialing A. A health insurer or its designee may recredential participating providers at least once every thirty-six months and more frequently if required by federal or state law or the health insurer’s accreditation standards, or if permitted by the health insurer’s contract with the participating provider. Nothing in this section shall affect the contract […]
§ 20-3459 – Civil immunity; enforcement; civil penalty
20-3459. Civil immunity; enforcement; civil penalty A. A health insurer that complies in good faith with the requirements of this chapter is immune from civil liability for the purposes of reviewing and approving a credentialing application. B. The director shall enforce this chapter. A health insurer that fails to comply with this chapter or with […]
§ 20-3501 – Definitions
20-3501. Definitions In this chapter, unless the context otherwise requires: 1. " Classification of benefits" means the following classifications of benefits provided by a health plan: (a) Inpatient, in-network. (b) Inpatient, out-of-network. (c) Outpatient, in-network. (d) Outpatient, out-of-network. (e) Emergency care. (f) Prescription benefits. 2. " Health care insurer" means a disability insurer, group disability […]
§ 20-3401 – Definitions
20-3401. Definitions In this article, unless the context otherwise requires: 1. " Adverse determination" : (a) Means a decision by a health care services plan or its utilization review agent that the health care services furnished or proposed to be furnished to an enrollee are not medically necessary and plan coverage is therefore denied, reduced […]
§ 20-3502 – Compliance with federal law; report
20-3502. Compliance with federal law; report A. Each health care insurer that issues a health plan in this state shall comply with the mental health parity and addiction equity act. B. After January 1, 2022, on a date specified by the director, each health care insurer that issues a health plan in this state shall […]
§ 20-3402 – Prior authorization; exceptions
20-3402. Prior authorization; exceptions A. A health care services plan or its utilization review agent may impose a prior authorization requirement for health care services provided to an enrollee, except for emergency ambulance services and emergency services as specified in section 20-2803, health care services arising after the initial medical screening examination and immediately necessary […]
§ 20-3503 – Enforcement and oversight
20-3503. Enforcement and oversight A. The department shall enforce this chapter. B. On or before January 1, 2021, the department shall develop a web page that provides the following information in nontechnical and readily understandable language: 1. Consumer-friendly information concerning the scope and applicability of the mental health parity and addiction equity act and the […]
§ 20-3403 – Prior authorization requirements; disclosures; access
20-3403. Prior authorization requirements; disclosures; access A. If a health care services plan contains a prior authorization requirement, all of the following apply: 1. The health care services plan or its utilization review agent shall make available to all providers on its website or provider portal a listing of all prior authorization requirements. The listing […]