§ 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 […]
§ 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 […]
§ 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) […]
§ 9409. Health care provider bargaining groups
§ 9409. Health care provider bargaining groups (a) The Green Mountain Care Board may approve the creation of one or more health care provider bargaining groups, consisting of health care providers who choose to participate. A bargaining group is authorized to negotiate on behalf of all participating providers with the Secretary of Administration, the Secretary […]
§ 9410. Health care database
§ 9410. Health care database (a)(1) The Board shall establish and maintain a unified health care database to enable the Board to carry out its duties under this chapter, chapter 220 of this title, and Title 8, including: (A) determining the capacity and distribution of existing resources; (B) identifying health care needs and informing health […]
§ 9411. Interactive price transparency dashboard
§ 9411. Interactive price transparency dashboard (a) The Green Mountain Care Board shall develop and maintain a public, interactive, Internet-based price transparency dashboard that allows consumers to compare health care prices for certain health care services across the State. Using data from the Vermont Healthcare Claims Uniform Reporting and Evaluation System (VHCURES) established pursuant to […]
§ 9412. Enforcement
§ 9412. Enforcement (a) In order to carry out the duties under this chapter, in addition to the powers provided in this chapter, in chapter 220 of this title, and in Title 8, the Commissioner and the Board may examine the books, accounts, and papers of health insurers, health care providers, health care facilities, health […]
§ 9413. Health care quality and price comparison
§ 9413. Health care quality and price comparison Each health insurer with more than 200 covered lives in this State shall establish an Internet-based tool to enable its members to compare the price of health care in Vermont by service or procedure, including office visits, emergency care, radiologic services, and preventive care such as mammography […]