December 25, 2024 Clouds

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Chapter 176O

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