§ 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 […]
§ 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) […]
§ 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 […]