420-J:1 Purpose and Intent. – The purpose and intent of this chapter is to provide standards for certain fundamental operations of licensed entities providing health insurance through a managed care system of health care delivery and reimbursement. The establishment of these standards will ensure regulatory and quality consistency among the several and various licensees […]
420-J:10 Confidentiality of Insurer Records. – I. Data or information pertaining to the diagnosis, treatment, or health of a covered person obtained from the person or from a provider by a health carrier is confidential and shall not be disclosed to any person except to the extent that it may be necessary to carry […]
420-J:11 Confidentiality of Insurance Department Records. – All information, documents and copies thereof obtained by or disclosed to the commissioner or any other person in the course of an examination or investigation made pursuant to RSA 400-A:37, and, unless otherwise provided in this chapter, all information reported and maintained pursuant to this chapter shall […]
420-J:12 Rulemaking Authority. – The commissioner may adopt such rules, under RSA 541-A, and issue such orders as may be necessary to carry out the purposes and provisions of this chapter. Source. 1997, 345:1, eff. Jan. 1, 1998.
420-J:13 Severability. – If any provision of this chapter or the application thereof to any person or circumstance is held invalid, the invalidity does not affect other provisions or applications of the chapter which can be given effect without the invalid provisions or applications, and to this end the provisions of this chapter are […]
420-J:14 Penalties. – Any health carrier or other organization violating any of the provisions of this chapter may be subject to an administrative fine not to exceed $2,500 per violation. The commissioner may also suspend or revoke the certificate of authority or license of a health carrier or other organization for any violation of […]
420-J:15 Definitions. – In this subdivision: I. " ASAM criteria " means the latest edition of the Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, developed by the American Society of Addiction Medicine. II. " Clinical stabilization services " means 24-hour clinically-managed post-withdrawal management treatment for adults or adolescents which may include intensive education […]
420-J:16 Levels of Care Criteria; Attestation. – I. Whenever substance use disorder services are a covered benefit under a health benefit plan subject to this chapter, the health carrier providing such benefits shall rely upon ASAM criteria when determining medical necessity and developing utilization review standards for levels of care for substance use disorder […]
420-J:17 Prior Authorization. – I. Whenever substance use disorder services are a covered benefit under a health benefit plan subject to this chapter, no prior authorization shall be required for the first 2 routine outpatient visits of an episode of care by an individual for assessment and care with respect to a substance use […]
420-J:18 Authorization for Medication-Assisted Treatment. – Whenever substance use disorder services are a covered benefit under a health benefit plan subject to this chapter, a health carrier shall: I. Be required to offer at least one medication-assisted treatment therapy option approved by the federal Food and Drug Administration for treatment of substance use disorders […]
420-J:19 Medication Synchronization. – I. An individual or group health insurance plan or policy providing prescription drug coverage in New Hampshire, shall permit and apply a prorated, daily cost-sharing rate to covered prescriptions for a chronic condition that are dispensed by an in-network pharmacy for less than a 30-day supply if the prescriber and […]
420-J:2 Applicability and Scope. – This chapter shall apply to all health carriers offering a managed care plan in this state. Source. 1997, 345:1, eff. Jan. 1, 1998.
420-J:3 Definitions. – In this chapter: I. "Adverse determination" means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay or other health care service has been reviewed and, based upon the information provided, does not meet the health carrier’s requirements for medical necessity, […]
420-J:3-a Access to Enhanced 911 System. – I. No health benefit plan issued or renewed after July 7, 2000 shall contain any provision which establishes or promotes an emergency medical response or transportation system that encourages or directs access by a covered person in competition with or in substitution of the state enhanced 911 […]
420-J:3-b Pre-certification Requirement. – In the event that a person is covered by more than one plan that requires pre-certification, the member shall obtain pre-certification from the primary plan. Although the member shall not be required to obtain pre-certification from the secondary plan, the secondary plan shall not be required to treat such services […]
420-J:4 Credentialing Verification Procedures. – I. A health carrier shall: (a) Establish written policies and procedures for credentialing verification of all health care professionals with whom the health carrier contracts and apply these standards consistently. (b) Verify the credentials of a health care professional. Prior to completion of credentialing verification the health carrier shall: […]
420-J:4-a Facility Credentialing. – I. Health carriers shall credential qualified entities administering community mental health programs as defined under RSA 135-C:7, entities administering community substance use disorder treatment programs as defined under RSA 172:2-c, and community health centers as facilities when paneling and enrolling participating providers, consistent with health carriers’ facility credentialing standards and […]
420-J:5 Grievance Procedures. – Every carrier or other licensed entity shall establish and shall maintain a written procedure by which a claimant or a representative of the claimant, shall have a reasonable opportunity to appeal a claim denial to the carrier or other licensed entity, and under which there shall be a full and […]
420-J:5-a Right to External Review. – I. A covered person shall have the right to independent external review of a determination by a health carrier or its designee utilization review entity when all of the following conditions apply: (a) The subject of the request for external review is an adverse determination; (b) The covered […]
420-J:5-b Standard External Review. – Standard external review shall be conducted as follows: I. Within 7 business days after the date of receipt of a request for external review, the commissioner shall complete a preliminary review of the request to determine whether: (a) The individual is or was a covered person under the health […]
