§1260.33. Notice requirements

A. Timing of notice to physician or provider of grace period status.

(1) When a physician or other healthcare provider or his representative requests information regarding an enrollee from a qualified health plan issuer about eligibility, coverage, or health plan benefits, or the status of a claim or claims for services provided, and the request or service is for a date within the second or third month of a grace period, the qualified health plan issuer shall clearly identify that the applicable enrollee is in the grace period and provide additional information as required by this Subpart.

(2) Unless the qualified health plan issuer makes the notice available on its website or by other electronic means, the qualified health plan issuer shall provide the notice through the same medium through which the physician or other healthcare provider or his representative sought the information from the qualified health plan issuer pursuant to Paragraph (1) of this Subsection.

(3) The information provided about the enrollee's grace period status shall be binding on the qualified health plan pursuant to this Subpart.

B. Specific notice requirements.

(1) If the qualified health plan issuer informs the physician or other healthcare provider or his representative that the enrollee is eligible for services but not that the enrollee is in the grace period, the determination shall be binding on the qualified health plan issuer and it shall pay the claims for covered services in accordance with the qualified health plan.

(2) The binding determination shall preclude the qualified health plan issuer from seeking to recoup payment from the physician or other healthcare provider for services rendered during the grace period.

(3) If the qualified health plan issuer informs the physician or other healthcare provider that the enrollee is in a grace period, he shall then provide further notification pursuant to Subsection C of this Section.

C. Contents of notice. The notice to the physician or other healthcare provider shall include but not be limited to the following:

(1) Purpose of the notice.

(2) The full legal name of the enrollee and any unique identifying numbers.

(3) The name of the qualified health plan.

(4) The unique health plan identifier of the qualified health plan.

(5) The name of the qualified health plan issuer.

(6) The specific date upon which the grace period for the enrollee began and the specific date upon which the grace period will expire.

D. Required information. In a conspicuous location on a qualified health plan website, the qualified health plan issuer shall provide the following information:

(1) Whether the qualified health plan issuer will hold any claims of the physician or other healthcare provider for services that the physician or other healthcare provider furnishes to the enrollee during the grace period.

(2) A statement indicating that should the qualified health plan issuer indicate that it will pay some or all of the claims for services provided to an enrollee during the grace period, whether and how it will seek to recoup claims payments made to physicians or healthcare providers for services furnished during the grace period.

Acts 2014, No. 174, §1.