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General Laws

Section 7. Every registered physician, chiropractor and nurse midwife shall have the right, on complying with such rules and regulations as the corporation may make, to enter into a written agreement with a medical service corporation, doing business in the city or town where the said physician, chiropractor or nurse midwife resides or has a usual place of business, to perform medical, chiropractic, or midwifery services. A medical service corporation shall not refuse to contract with or compensate for covered services an otherwise eligible provider solely because such provider has in good faith communicated with one or more of his current, former or prospective patients regarding the provisions, terms or requirements of the medical service corporation’s products as they relate to the needs of such provider’s patients. No participating physician or other participating provider of health services shall charge to or collect from a subscriber or covered dependent any amount in excess of the amount of compensation determined and allowed by a medical service corporation pursuant to the applicable method of compensation approved by the commissioner, except when such subscriber or covered dependent (a) is eligible for benefits under a subscription certificate containing a provision permitting such charge or collection when the subscriber or covered dependent (i) is entitled to receive reimbursement or compensation from a third party for the cost of the same or similar services or (ii) receives money or its equivalent as a result of a claim against a third party for loss or damages for personal injuries, and only in the circumstances and to the extent so permitted, or (b) is eligible for benefits under a subscription certificate which provides for compensation to a participating physician or other participating provider of health services under a nonprofit medical service plan previously approved by the commissioner, the so-called “Plan B”, and has an annual income in excess of seven thousand five hundred dollars, or (c) is eligible for benefits under a subscription certificate under a group medical service agreement containing a provision describing the specific circumstances under which and the extent to which additional amounts may be charged or collected; provided, however, that such provision has first been approved in writing by the commissioner and has been requested by the employer, employers or other representatives of the group to which it applies, and only in the circumstances and to the extent so described. This chapter shall not change the relations between physician, chiropractor, or nurse midwife and patient. No restriction shall be placed by any such corporation upon its participating physicians, chiropractors, or nurse midwives as to methods of diagnosis or treatment. No officer, agent, or employee of a medical service corporation shall influence or attempt to influence a subscriber or a covered dependent in the choice of a participating physician, chiropractor, or nurse midwife. A subscriber or a covered dependent, subject to the by-laws, rules and regulations of a medical service corporation and the terms and provisions of the subscription certificate, shall be entitled to the benefits of this chapter upon receiving medical, chiropractic, or midwifery service from any participating physician, chiropractor, or nurse midwife or, in the discretion of the corporation, upon receiving medical, chiropractic or midwifery service from any non-participating physician, chiropractor, or nurse midwife in an emergency or when outside the commonwealth. A corporation may terminate its agreement with any participating physician, chiropractor, nurse midwife or any other participating provider of health services licensed under the laws of the commonwealth at any time (a) for failure to comply with the reasonable rules and regulations of such corporation, including without limitation, such rules and regulations governing the keeping of accounts, records and statistics, the making of reports and proof of services rendered, or (b) for presenting any fraudulent, unreasonable, or improper claim for payment, or compensation.

No such agreement may be terminated by a medical service corporation unless such corporation shall first have given the participating physician or other provider of health services a written statement of the charges against him or her, an opportunity for hearing, reasonable notice of the time and place of hearing, and a written decision accompanied by a statement of the reasons for the decision. A participating physician or other provider of health services shall also have (a) the right, within 45 days after receipt by a medical service corporation from a provider of a completed claim form for covered services, to receive (i) payment, (ii) notice of the reasons for any nonpayment or (iii) notice of additional information or documentation necessary to establish entitlement to payment; (b) the right, upon request following denial of entitlement to payment for covered service because such services were determined by a medical service corporation to be unnecessary for the medical or other health care of a subscriber or covered dependent to a formal peer review process; (c) the right to inspect a listing of his or her usual charges maintained by a medical service corporation; (d) the right to inspect a listing of customary charges maintained by a medical service corporation which are applicable to his or her services; and (e) the right to a copy of the bylaws of a medical service corporation and rules and regulations adopted by the board of directors of such a corporation. If the medical service corporation fails to comply with the provisions of this paragraph, said corporation shall pay, in addition to any benefits which inure to such subscriber or provider, interest on such benefits, which shall accrue beginning 45 days after the corporation’s receipt of notice of claim at the rate of one and one-half percent per month, not to exceed eighteen percent per year. The provisions of this paragraph relating to interest payments shall not apply to a claim which a medical service corporation is investigating because of suspected fraud.

A participating physician or other professional provider of health services may terminate his or her agreement with a medical service corporation at any time upon giving not less than one year notice in writing to the medical service corporation and each of his patients to terminate as of a date specified in such notice; provided however, that any physician or provider giving such notice shall not terminate any physician-patient relationship after the one-year notice period with any subscriber or covered dependent unless and until arrangements have been made for appropriate referrals, continuation, and follow-up care. Until such time as a patient or subscriber has been referred to and has established a physician-patient relationship with another participating physician, the medical services corporation shall continue to provide compensation to the terminating physician or provider at the rate allowed for such services prior to termination and said terminating physician or provider shall not be allowed to charge the patient any additional amount for such services.

Nothing in this section shall limit or derogate from the rights of beneficiaries of health insurance under Title XVIII of the federal Social Security Act to the benefits of chapter four hundred and seventy-five of the acts of nineteen hundred and eighty-five.

Every participating provider shall receive from a medical service corporation not less than annually a handbook, written in plain English and subject to the commissioner’s approval, that explains said corporation’s methods of payment, including but not limited to, all requirements for the submission of charges, all restrictions on payments, an explanation of the usual and customary charge system and methods of updating a provider’s charge profile. Said handbook shall be made available to participating providers at least six months prior to any annual update of charge profiles.

A subscriber who is eligible for benefits supplemental to Part B of Title XVIII of the Social Security Act, as amended, under a nongroup medical service agreement, or a subscription certificate issued thereunder, or under a group medical service agreement shall be entitled to the benefits provided therein, including payments for the services of a participating or nonparticipating physician to be made by a medical service corporation to the subscriber or to the physician as such payments are made for the services under Part B of Title XVIII of the Social Security Act, as amended.

Nothing in this section shall be construed to allow a physician, who receives payment under a supplemental program of coverage to medicare, or other governmental programs, to charge to, or collect from, a subscriber or covered dependent any amount in excess of the maximum allowable compensation determined by the governmental agency administering such program as the basis for the government’s payment thereunder to such physician.

Nothing in section four or in this section shall be construed to prohibit any medical service corporation from entering into written agreements with its subscribers and with participating chiropractors to furnish chiropractic services to subscribers and covered dependents or from including chiropractic services in its nonprofit medical service plan, nor shall any medical service corporation discriminate in any way against participating chiropractors in the furnishing of chiropractic service to its subscribers and covered dependents.

Nothing in section four or in this section shall be construed to prohibit any medical service corporation from entering into written agreements with its subscribers and with participating nurse midwives to furnish midwifery services to subscribers and covered dependents or from including midwifery services in its non-profit medical service plan, nor shall any medical service corporation discriminate in any way against participating nurse midwives in the furnishing of midwifery service to its subscribers and covered dependents.

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