20-3111. Definitions In this article, unless the context otherwise requires: 1. " Arbitration" means a dispute resolution process in which an impartial arbitrator determines the dollar amount a health care provider is entitled to receive for payment of a surprise out-of-network bill. 2. " Arbitrator" means an impartial person who is appointed to conduct an […]
20-3112. Applicability This article does not apply to: 1. Health care services that are not covered by the enrollee’s health plan. 2. Limited benefit coverage as defined in section 20-1137. 3. Charges for health care services that are subject to a direct payment agreement under section 32-3216 or 36-437. 4. Health plans that do not […]
20-3113. Surprise out-of-network bill; requirements; notice A. A bill for a health care service that was provided in a network facility by a health care provider that is not a contracted provider must meet one of the following requirements to qualify as a surprise out-of-network bill: 1. The bill was for emergency services, including under […]
20-3114. Dispute resolution; settlement teleconference; arbitration; surprise out-of-network bills A. An enrollee who has received a surprise out-of-network bill and who disputes the amount of the bill may seek dispute resolution of the bill by filing a request for arbitration with the department not later than one year after the date of service noted in […]
20-3115. Conduct of arbitration proceedings A. The department shall develop a simple, fair, efficient and cost-effective arbitration procedure for surprise out-of-network bill disputes and specify time frames, standards and other details of the arbitration proceeding, including procedures for scheduling and notifying the parties of the settlement teleconference required by subsection E of this section. The […]
20-3116. Arbitrator qualifications To qualify as an arbitrator, a person shall have at least three years’ experience in health care services claims and shall comply with any other qualifications established by the department.
20-3117. Dispute resolution; notice of rights A. The department in conjunction with the appropriate health care boards shall prescribe the notice outlining an enrollee’s rights to dispute surprise out-of-network bills under this article. B. Health insurers shall include the notice prescribed pursuant to subsection A of this section in each explanation of benefits or other […]
20-3118. Surprise out-of-network bills; annual report A. On or before December 31, 2019 and each December 31 thereafter, the department shall report on the resolution of disputed surprise out-of-network bills. The report shall include: 1. The total number of inquiries regarding dispute resolution of surprise out-of-network bills. 2. The total number of requests that did […]
20-3119. Right of civil action An enrollee who is aggrieved by an arbitration decision regarding a disputed surprise out-of-network bill may file a civil action in superior court not later than one year after the date of the disputed decision to obtain appropriate relief with respect to the same surprise out-of-network bill.
