SCS/SBs 391 & 395 - This act makes various changes regarding how health carriers, providers, and their patients interact.

PROMPT PAY - Under this act, a health carrier must pay a clean claim within 45 days. The current statute does not mention the term "clean claim". The act defines a "clean claim" as a claim that has no defect or impropriety and which does not lack any required substantiating documentation. On or after April 1, 2002, a health carrier may request additional information by sending a notice that additional information is needed to determine if the claim is to be paid. Under this act, a health carrier may combine interest payments and make payment once the aggregated amount reaches five dollars.

After April 1, 2002, health care professionals will be required to file all reimbursement claims using the HCFA 1500 universal form. Under this act, health carriers shall permit non-participating health care professionals to file a reimbursement claim for a period of up to one year from the date of service. Participating health care professionals shall have six months to file a claim for reimbursement unless the contract between the health carrier and professional specifies a different standard. A health carrier shall not request a refund or offset a claim more than 12 months after it has paid the claim except in cases of fraud or misrepresentation by the health care professional. A health carrier must issue a confirmation of receipt of an electronically filed claim within 24 hours. On or after January 1, 2003, all reimbursement claims must be submitted in an electronic format consistent with federal guidelines. Any claims filed in a non-electronic format after this date will not be governed by the late payment provisions of section 376.383. This act also requires the director of the Department of Insurance to appoint a task force to develop industry standards for the electronic exchange of reimbursement claims. (Sections 376.383 and 376.384). This portion of the act is similar to SB 391 (2001).

OVERSIGHT OF PROVIDERS - A health carrier must currently maintain an adequate network of providers and monitor their ability to provide benefits. New language prohibits requiring providers to submit income tax returns, however, a health carrier may request a financial statement if the provider received one percent or more of the carrier's total medical expenditures. (Section 354.603) This act also removes the requirement that a health carrier monitor the financial capability of its providers.

OB/GYN SERVICES - In certain circumstances, health carriers must currently offer an open referral health plan. New language allows members to receive direct access to OB/GYNs within the provider network. No additional copayments should be charged for such services unless they charged for all services in the network. (Section 354.618) A similar provision is contained in TAT CCS/SS/SCS/HS/HCS/HB 762 (2001), TAT CCS/HS/HCS/SCS/SB 266 (2001) and SB 424 (2001).

NEWBORN COVERAGE - Currently, coverage must be provided for newborns up to thirty-one days after birth. New language requires the health carrier to provide an enrollee with the forms necessary to continue coverage of the child after thirty-one days, if necessary. Ten additional days will be allowed for the completion of such forms. This section applies to plans current as of August 28, 2001. (Section 376.406)

HOLD HARMLESS CLAUSES - A new section is created to define a "hold harmless clause" as an agreement by a health care provider to assume sole liability for services provided. Any contract between a provider and carrier must include a clause stating their liability for negligence or intentional wrongdoing. Each party shall hold the other party harmless against such claims. (Section 376.419)

COBRA NOTIFICATION OF SPOUSAL COVERAGE - Currently, separated, divorced, or widowed spouses may continue coverage of the other spouse's insurance through COBRA. Notice must be provided by the plan to the spouse. New language requires the notice to include a statement that the insurer will provide both parents with coverage information on any child covered by the policy. (Sections 376.893 - 376.895)

Similar provisions of this act are contained TAT SCS/HS/HCS/HBs 328 & 88 (2001).
STEPHEN WITTE