Chapter 176O: HEALTH INSURANCE CONSUMER PROTECTIONS
- Section 1 Definitions
- Section 2 Bureau of managed care
- Section 3 Complaints against carriers; notice; hearing
- Section 4 Refusal of carriers to contract with eligible health, dental or vision care providers solely because providers have practiced good faith advocacy on behalf of patients
- Section 5 Contracts; liability
- Section 5A Acceptance and recognition of information submitted pursuant to current coding standards and guidelines required; use of standardized claim formats
- Section 5B Policies and procedures to enforce Sec. 5A
- Section 5C Failure of carrier to comply with coding standards and guidelines; notice; penalty
- Section 5D Establishment of base fee schedule for evaluation and management services for behavioral health providers
- Section 6 Evidence of coverage to be delivered to covered adults by health, dental and vision care providers; contents
- Section 7 Information provided by carrier upon enrollment or upon request
- Section 8 Failure by carrier to file annual statement; fine
- Section 9 Utilization review programs; annual attestations
- Section 9A Agreements or contracts between carrier and health care provider prohibited if containing certain provisions
- Section 9B Alternate payment arrangements involving downside risk prohibited without risk certificate
- Section 10 Contractual financial incentive plans
- Section 11 Rights of health benefit plans to include as providers religious non-medical providers
- Section 12 Utilization review
- Section 12A Step therapy protocol: prescription drugs: annual report
- Section 12B Commission on step therapy protocol; responsibilities; annual report
- Section 13 Formal internal grievance process; expedited resolution policy
- Section 14 Review panel; patient protection office
- Section 15 Disenrollment of provider; continuation of treatment; specialty health care coverage
- Section 16 Clinical decisions regarding medical treatment made by treating physicians; payment for health care services ordered by treating physician or primary care provider
- Section 17 Regulations; promulgation
- Section 18 Responsibility of carrier for behavioral health services compliance
- Section 19 Display of name and telephone number of health service manager on enrollment cards of carrier
- Section 20 Information provided to insured adults by behavioral health manager; submission of material changes; workers' compensation; preferred provider arrangements
- Section 21 Submission by carrier of annual comprehensive financial statement
- Section 22 Participation in medical assistance program as condition for participation in carrier's provider network
- Section 23 Disclosure by carrier upon request for network status of health care provider and estimated or maximum allowed amount or charge for a proposed admission, procedure or service and amount insured responsible to pay; establishment of toll-free telephone number and website
- Section 24 Internal appeals processes for risk-bearing provider organizations; patient's right to third-party advocate; external review process
- Section 25 Use and acceptance of specifically designated prior authorization forms
- Section 26 Establishment of standardized processes and procedures for the determination of patient's health benefit plan eligibility at or prior to time of service
- Section 27 Development and use of common summary of payments form; implementation of education plan
- Section 28 Provider directories; contents; audits; print copies; customer service contact information; accommodations; accuracy; updates
- Section 29 Health care provider credentialing