General Laws

Click to PrintPrint Page

Section 1Definitions
Section 2Bureau of managed care
Section 3Complaints against carriers; notice; hearing
Section 4Refusal 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 5Contracts; liability
Section 5AAcceptance and recognition of information submitted pursuant to current coding standards and guidelines required; use of standardized claim formats
Section 5BPolicies and procedures to enforce Sec. 5A
Section 5CFailure of carrier to comply with coding standards and guidelines; notice; penalty
Section 6Evidence of coverage to be delivered to covered adults by health, dental and vision care providers; contents
Section 7Information provided by carrier upon enrollment or upon request
Section 8Failure by carrier to file annual statement; fine
Section 9Utilization review programs; annual attestations
Section 9AAgreements or contracts between carrier and health care provider prohibited if containing certain provisions
Section 9BAlternate payment arrangements involving downside risk prohibited without risk certificate
Section 10Contractual financial incentive plans
Section 11Rights of health benefit plans to include as providers religious non-medical providers
Section 12Utilization review
Section 13Formal internal grievance process; expedited resolution policy
Section 14Review panel; patient protection office
Section 15Disenrollment of provider; continuation of treatment; specialty health care coverage
Section 16Clinical decisions regarding medical treatment made by treating physicians; payment for health care services ordered by treating physician or primary care provider
Section 17Regulations; promulgation
Section 18Responsibility of carrier for behavioral health services compliance
Section 19Display of name and telephone number of health service manager on enrollment cards of carrier
Section 20Information provided to insured adults by behavioral health manager; submission of material changes; workers' compensation; preferred provider arrangements
Section 21Submission by carrier of annual comprehensive financial statement
Section 22Participation in medical assistance program as condition for participation in carrier's provider network
Section 23Disclosure 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 24Internal appeals processes for risk-bearing provider organizations; patient's right to third-party advocate; external review process
Section 25Use and acceptance of specifically designated prior authorization forms
Section 26Establishment of standardized processes and procedures for the determination of patient's health benefit plan eligibility at or prior to time of service
Section 27Development of common summary of payments form