Chapter 176o - Health Insurance Consumer Protections

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

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