§ 9418f. Rental network contracts
§ 9418f. Rental network contracts (a) Definitions. As used in this section: (1) “Health care services” means services for the diagnosis, prevention, treatment, or cure of a health condition, illness, injury, or disease. (2)(A) “Provider” means a physician, a physician organization, or a physician hospital organization that is acting exclusively as an administrator on behalf […]
§ 9418g. Enforcement
§ 9418g. Enforcement In addition to any other remedy provided by law, the Commissioner may, in his or her sole discretion, enforce the provisions of this subchapter as specified in this section. In determining whether to undertake an enforcement action, the Commissioner may consider the relative resources of the complaining party and the alleged noncompliant […]
§ 9419. Charges for access to medical records
§ 9419. Charges for access to medical records (a) A custodian may impose a charge that is no more than a flat $5.00 fee or no more than $0.50 per page, whichever is greater, for providing copies of an individual’s health care record. A custodian shall provide an individual or the authorized recipient with an […]
§ 9418a. Processing claims, downcoding, and adherence to coding rules
§ 9418a. Processing claims, downcoding, and adherence to coding rules (a) Health plans, contracting entities, covered entities, and payers shall accept and initiate the processing of all health care claims submitted by a health care provider pursuant to and consistent with the current version of the American Medical Association’s Current Procedural Terminology (CPT) codes, reporting […]
§ 9418b. Prior authorization
§ 9418b. Prior authorization (a) Health plans shall pay claims for health care services for which prior authorization was required by and received from the health plan, unless: (1) the insured was not a covered individual at the time the service was rendered; (2) the insured’s benefit limitations were exhausted; (3) the prior authorization was […]
§ 9418c. Fair contract standards
§ 9418c. Fair contract standards (a) Required information. (1) Each contracting entity shall provide and each health care contract shall obligate the contracting entity to provide participating health care providers information sufficient for the participating provider to determine the compensation or payment terms for health care services, including all of the following: (A) The manner […]
§ 9417. Tax-advantaged accounts for health-related expenses; administration; rulemaking
§ 9417. Tax-advantaged accounts for health-related expenses; administration; rulemaking (a) As used in this section: (1) “Flexible spending account” or “FSA” has the same meaning as in 26 U.S.C. § 106(c)(2). (2) “Health reimbursement arrangement” or “HRA” means any account-based reimbursement arrangement funded solely by employer contributions that reimburses an employee, spouse, or dependents, or […]
§ 9418. Payment for health care services
§ 9418. Payment for health care services (a) Except as otherwise specified, as used in this subchapter: (1) “Claim” means any claim, bill, or request for payment for all or any portion of provided health care services that is submitted by: (A) a health care provider or a health care facility pursuant to a contract […]
§ 9408. Common claims forms and procedures
§ 9408. Common claims forms and procedures No later than January 15, 1993, the Commissioner shall adopt by rule uniform health insurance claims forms and uniform standards and procedures for the processing of claims, including electronic claims forms submission. (Added 1991, No. 160 (Adj. Sess.), § 1, eff. May 11, 1992; amended 1995, No. 180 […]
§ 9408a. Uniform provider credentialing
§ 9408a. Uniform provider credentialing (a) Definitions. As used in this section: (1) “Credentialing” means a process through which an insurer or hospital makes a determination, based on criteria established by the insurer or hospital, concerning whether a provider is eligible to: (A) provide health care services to an insured or hospital patients; and (B) […]