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  • PART I ADMINISTRATION OF THE GOVERNMENT
  • TITLE XXII CORPORATIONS
  • 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 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 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 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 of common summary of payments form