To repeal sections 354.400, 354.405, 354.410, 354.430, 354.470, 354.490, 354.505, 354.515, 354.535, 374.500, 374.507 and 374.510, RSMo 1994, and sections 376.381 and 376.811, RSMo Supp. 1996, relating to managed care organizations, and to enact in lieu thereof forty-eight new sections relating to the same subject, with penalty provisions.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF MISSOURI, AS FOLLOWS:

     Section A. Sections 354.400, 354.405, 354.410, 354.430, 354.470, 354.490, 354.505, 354.515, 354.535, 374.500, 374.507 and 374.510, RSMo 1994, and sections 376.381 and 376.811, RSMo Supp. 1996, are repealed and forty-eight new sections enacted in lieu thereof, to be known as sections 192.068, 354.400, 354.405, 354.410, 354.430, 354.441, 354.442, 354.443, 354.444, 354.470, 354.490, 354.505, 354.515, 354.535, 354.600, 354.603, 354.606, 354.609, 354.612, 354.615, 354.618, 354.621, 354.624, 354.627, 354.633, 354.636, 374.500, 374.507, 374.510, 376.381, 376.811, 376.1350, 376.1353, 376.1356, 376.1359, 376.1361, 376.1363, 376.1365, 376.1367, 376.1369, 376.1372, 376.1375, 376.1378, 376.1382, 376.1385, 376.1387, 376.1389 and 376.1390, to read as follows:

     192.068. 1. Any entity in the business of delivering or financing health care shall provide data regarding quality of care, access to care, member satisfaction and member health status to the director of the department of health. Failure to provide data as required by the director of the department of health pursuant to this section shall be reported to the director of the department of insurance and shall constitute a violation of the unfair trade practices act, sections 375.930 to 375.948, RSMo. Any health care financing entity or health care provider which continually or substantially fails to comply with the provisions of this section shall be restricted from participating in any health program administered by the state. The department of health shall define continual or substantial failure to comply with the provisions of this section.

     2. The department of health shall specify the types of data which shall be submitted and the methods of collection and submission. In defining data standards for the measurement of the quality of care, access to care, member satisfaction and member health status, the director of the department of health may:

     (1) Use as the minimal data set the Health Plan Employer Data and Information Set (HEDIS) or an equivalent data set as determined by the department of health;

     (2) Consider published standards developed by nationally recognized accreditation organizations including, but not limited to, the National Committee for Quality Assurance and the Joint Committee on Accreditation of Health Care Organizations;

     (3) Appoint and consult with a committee comprised of the directors of the departments or a designee and other interested parties responsible for delivering, financing and purchasing health care in the state; and

     (4) Use available department of health data and other agency data wherever appropriate.

     3. Data or other information obtained by the department of health under the provisions of this section shall not be public information. Reports and studies prepared by the department based upon such information shall be public information and may identify individual entities in the business of delivering or financing health care. Reports prepared for internal quality assurance which may have statistical limitations shall not be public information. The department of health may authorize the use of the data for other research pursuant to the provisions of section 192.067. The department shall not release data in a form which could be used to identify a patient.

     4. The department may choose to perform studies and shall publish information, including at least an annual consumer guide, based upon the information obtained pursuant to the provisions of this section. The department shall allow health care financing entities or health care providers who have submitted data which will be used in any report to review and comment on the report prior to its publication or release for public use. With the permission of the entity or the health care provider, the department may include any comments of a health care financing entity or health care provider in the publication. The reports shall be made available to the public. The department may charge a reasonable fee to any entity in the business of delivering or financing health care for specialized reports or services requested by such entity. The fees shall be credited to the public health services fund established in section 192.900.

     354.400. As used in sections 354.400 to 354.550, the following terms shall mean:

     (1) "Basic health care services", health care services which an enrolled population might reasonably require in order to be maintained in good health, including, as a minimum, emergency care, inpatient hospital and physician care, and outpatient medical services;

     (2) "Director", the director of the department of insurance;

     (3) "Emergency", a medical condition, the onset of which is sudden, of recent onset, or involves the exacerbation of a chronic condition, that manifests itself by symptoms of sufficient severity, which may include severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention to result in:

     (a) Placing the person's health in significant jeopardy;

     (b) Serious impairment to a bodily function;

     (c) Serious dysfunction of any bodily organ or part;

     (d) Inadequately controlled pain; or

     (e) With respect to a pregnant woman who is having contractions:

     a. That there is inadequate time to effect a safe transfer to another hospital before delivery; or

     b. That transfer to another hospital may pose a threat to the health or safety of the woman or unborn child;

     (4) "Emergency services", health care services that are provided in a licensed hospital's emergency facility by an appropriate provider to the extent that they are required to evaluate and treat an emergency medical condition until the condition is stabilized;

     (5) "Enrollee", an individual who has been enrolled in a health maintenance organization;

     [(4)] (6) "Evidence of coverage", any certificate, agreement, or contract issued to an enrollee setting out the coverage to which [he] the enrollee is entitled;

     [(5)] (7) "Health care services", any services included in the furnishing to any individual of medical or dental care or hospitalization, or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability;

     [(6)] (8) "Health maintenance organization", any person which undertakes to provide or arrange for basic and supplemental health care services to enrollees on a prepaid basis, or which meets the requirements of section 1301 of the United States Public Health Service Act;

     [(7)] (9) "Health maintenance organization plan", any arrangement whereby any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services and at least part of such arrangement consists of providing and assuring the availability of basic health care services to enrollees, as distinguished from mere indemnification against the cost of such services, on a prepaid basis through insurance or otherwise, and as distinguished from the mere provision of service benefits under health service corporation programs;

     [(8)] (10) "Individual practice association", a partnership, corporation, association, or other legal entity which delivers or arranges for the delivery of health care services and which has entered into a services arrangement with persons who are licensed to practice medicine, osteopathy, dentistry, chiropractic, pharmacy, podiatry, optometry, or any other health profession and a majority of whom are licensed to practice medicine or osteopathy. Such an arrangement shall provide:

     (a) That such persons shall provide their professional services in accordance with a compensation arrangement established by the entity; and

     (b) To the extent feasible for the sharing by such persons of medical and other records, equipment, and professional, technical, and administrative staff;

     [(9)] (11) "Medical group/staff model", a partnership, association, or other group:

     (a) Which is composed of health professionals licensed to practice medicine or osteopathy and of such other licensed health professionals (including dentists, chiropractors, pharmacists, optometrists, and podiatrists) as are necessary for the provisions of health services for which the group is responsible;

     (b) A majority of the members of which are licensed to practice medicine or osteopathy; and

     (c) The members of which (i) as their principal professional activity over fifty percent individually and as a group responsibility engaged in the coordinated practice of their profession for a health maintenance organization; (ii) pool their income from practice as members of the group and distribute it among themselves according to a prearranged salary or drawing account or other plan, or are salaried employees of the health maintenance organization; (iii) share medical and other records and substantial portions of major equipment and of professional, technical, and administrative staff; (iv) establish an arrangement whereby an enrollee's enrollment status is not known to the member of the group who provides health services to the enrollee;

     [(10)] (12) "Person", any partnership, association, or corporation;

     [(11)] (13) "Provider", any physician, hospital, or other person which is licensed or otherwise authorized in this state to furnish health care services;

     [(12)] (14) "Uncovered expenditures", the costs of health care services that are covered by a health maintenance organization, but that are not guaranteed, insured, or assumed by a person or organization other than the health maintenance organization, or those costs which a provider has not agreed to forgive enrollees if the provider is not paid by the health maintenance organization.

     354.405. 1. Notwithstanding any law of this state to the contrary, any person may apply to the director for a certificate of authority to establish and operate a health maintenance organization in compliance with this act. No person shall establish or operate a health maintenance organization in this state without obtaining a certificate of authority under sections 354.400 to 354.550. A foreign corporation may qualify under sections 354.400 to 354.550, subject to its registration to do business in this state as a foreign corporation under chapter 351, RSMo, and compliance with the provisions of sections 354.400 to 354.550.

     2. Every health maintenance organization doing business in this state on September 28, 1983, shall submit an application for a certificate of authority under subsection 3 of this section within one hundred twenty days of September 28, 1983. Each such applicant may continue to operate until the director acts upon the application. In the event that an application is not submitted or is denied under section 354.410, the applicant shall henceforth be treated as a health maintenance organization whose certificate of authority has been revoked. Any health maintenance organization licensed by the department of insurance prior to September 28, 1983, and complying with the paid-in capital or guarantee fund requirements of section 354.410 shall be issued a certificate of authority upon filing an amended certificate of authority and an amended articles of incorporation that conform with sections 354.400 to 354.550. When the annual statement of a health maintenance organization subject to the provisions of sections 354.400 to 354.550 is filed and all fees due from the health maintenance organization are tendered, the health maintenance organization's certificate of authority to do business in this state shall automatically be extended pending formal renewal by the director, or until such time as [he] the director should refuse to renew the certificate.

     3. Each application for a certificate of authority shall be verified by an officer or authorized representative of the applicant, shall be in a form prescribed by the director, and shall set forth or be accompanied by the following:

     (1) A copy of the organizational documents of the applicant such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents, and all amendments thereto;

     (2) A copy of the bylaws, rules and regulations, or similar document, if any, regulating the conduct of the internal affairs of the applicant;

     (3) A list of the names, addresses, and official positions of the persons who are to be responsible for the conduct of the affairs of the applicant, including all members of the board of directors, board of trustees, executive committee, or other governing board or committee, the principal officers if the applicant is a corporation, and the partners or members if the applicant is a partnership or association;

     (4) A copy of any contract made or to be made between any providers and persons listed in subdivision (3) of this subsection and the applicant;

     (5) A copy of the form of evidence of coverage to be issued to the enrollees;

     (6) A copy of the form of the group contract, if any, which is to be issued to employers, unions, trustees, or other organizations;

     (7) Financial statements showing the applicant's assets, liabilities, and sources of financial support. If the applicant's financial affairs are audited by independent certified public accountants, a copy of the applicant's most recent certified financial statement shall be deemed to satisfy this requirement unless the director directs that additional or more recent financial information is required for the proper administration of sections 354.400 to 354.550;

     (8) A description of the proposed method of marketing the plan, a financial plan which includes a three-year projection of operating results anticipated, and a statement as to the sources of working capital as well as any other sources of funding;

     (9) If the applicant is not domiciled in this state, a power of attorney duly executed by such applicant appointing the director, [his] the director's successors in office, and duly authorized deputies, as the true and lawful attorney of such applicant in and for this state upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising in this state may be served;

     (10) A statement reasonably describing the geographic area or areas to be served;

     (11) A description of the complaints procedures to be utilized as required by section 354.445;

     (12) A description of the mechanism by which enrollees will be afforded an opportunity to participate in matters of policy and operation;

     (13) Evidence demonstrating that the health care organization has provided its enrollees with adequate access to health care providers; and

     (14) Such other information as the director may require to make the determinations required in section 354.410.

     4. Every health maintenance organization shall file with the director notice of its intention to modify any of the procedures or information described in and required to be filed by this section. Such notice shall be [filed with] approved by the director prior to the actual modification. [If the director does not disapprove the modification within thirty days of filing, such modification shall be deemed approved.] The director shall approve or disapprove the modification in writing within sixty days of filing for the first year after the effective date of this section and within thirty days for all subsequent years. If the director does not disapprove the modification within sixty days of filing for the first year after the effective date of this section and within thirty days of filing for all subsequent years, such modification shall be deemed approved.

     5. A health maintenance organization shall file all contracts of reinsurance. Any agreement between the organization and an insurer shall be subject to the laws of this state regarding reinsurance. All reinsurance agreements and any modifications thereto must be filed and approved.

     6. When he deems it appropriate, the director may exempt any item from the filing requirements of this section.

     354.410. 1. The director shall issue or deny a certificate of authority to any person filing an application pursuant to section 354.405. Issuance of a certificate of authority may then be granted upon payment of the application fee prescribed in section 354.500 if the director is satisfied that the following conditions are met:

     (1) The persons responsible for the conduct of the affairs of the applicant are competent, trustworthy, and possess good reputations;

     (2) The health care organization constitutes an appropriate mechanism whereby the health maintenance organization will effectively provide or arrange for the provision of basic health care services on a prepaid basis through insurance or otherwise, except to the extent of reasonable requirements for copayments;

     (3) The health maintenance organization is financially responsible and may reasonably be expected to meet its obligations to enrollees and prospective enrollees. In making this determination, the director may consider:

     (a) The financial soundness of the arrangements for health care services and the schedule of charges used in connection therewith;

     (b) The adequacy of working capital;

     (c) Any agreement with an insurer, a government, or any other organization for insuring the payment of the cost of health care services or the provision for automatic applicability of an alternative coverage in the event of discontinuance of the health maintenance organization;

     (d) Any agreement with providers for the provision of health care services; and

     (e) Any deposit of cash or securities submitted in accordance with subsection 2;

     (4) The health maintenance organization's arrangements for health care services and the schedule of charges used in connection therewith are financially sound;

     (5) The working capital be adequate;

     (6) Any agreement with an insurer, a health service corporation, a government, or any other organization for insuring the payment of the cost of health care services contain a provision for the automatic applicability of alternative coverage in the event of discontinuance of the health maintenance organization;

     (7) There be an agreement with providers for the provision of health care services;

     (8) The enrollees will be afforded an opportunity to participate in matters of policy and operation pursuant to section 354.420;

     (9) Nothing in the proposed method of operation, as shown by the information submitted pursuant to section 354.405 or by independent investigation, is contrary to the public interest;

     (10) The health care organization can provide its enrollees with adequate access to health care providers.

     2. Unless otherwise provided below, each health maintenance organization shall deposit with the director, or with any organization or trustee acceptable to him through which a custodial or controlled account is utilized, cash, securities, or any combination of these or other measures that is acceptable to him in the amount set forth in this subsection:

     (1) The amount for an organization that is beginning operation shall be the greater of: (a) five percent of its estimated expenditures for health care services for its first year of operation, (b) twice its estimated average monthly uncovered expenditures for its first year of operation, or (c) one hundred fifty thousand dollars for a medical group/staff model, or three hundred thousand dollars for an individual practice association. At the beginning of each succeeding year, unless not applicable, the organization shall deposit with the director, or organization or trustee, cash, securities, or any combination of these or other measures acceptable to the director, in an amount equal to four percent of its estimated annual uncovered expenditures for that year.

     (2) Unless not applicable, an organization that is in operation on September 28, 1983, shall make a deposit equal to the larger of: (a) one percent of the preceding twelve months uncovered expenditures, or (b) one hundred fifty thousand dollars for a medical group/staff model, or three hundred thousand dollars for an individual practice association on the first day of the first calendar year beginning six months or more after September 28, 1983. In the second calendar year, if applicable, the amount of the additional deposit shall be equal to two percent of its estimated annual uncovered expenditures. In the third calendar year, if applicable, the additional deposit shall be equal to three percent of its estimated annual uncovered expenditures for that year, and in the fourth calendar year and subsequent years, if applicable, the additional deposit shall be equal to four percent of its estimated annual uncovered expenditures for each year. Each year's estimate, after the first year of operation, shall reasonably reflect the prior years' operating experience and delivery arrangements. The director may waive any of the deposit requirements set forth in subdivisions (1) and (2) above, whenever satisfied that the organization has sufficient net worth and an adequate history of generating net income to assure its financial viability for the next year, or its performance and obligations are guaranteed by an organization with sufficient net worth and an adequate history of generating net income, or the assets of the organization or its contracts with insurers, hospital or medical service corporations, governments, or other organizations are sufficient to reasonably assure the performance of its obligations.

     3. When an organization has achieved a net worth not including land, buildings, and equipment, of at least one million dollars or has achieved a net worth including organization-related land, buildings, and equipment of at least five million dollars, the annual deposit requirements shall not apply. The annual deposit requirement shall not apply to an organization if the total amount of the deposit is equal to twenty-five percent of its estimated annual uncovered expenditures for the next calendar year, or the capital and surplus requirements for the formation or admittance of an accident and health insurer in this state, whichever is less. If the organization has a guaranteeing organization which has been in operation for at least five years and has a net worth not including land, buildings, and equipment of at least one million dollars or which has been in operation for at least ten years and has a net worth including organization-related land, buildings, and equipment of at least five million dollars, the annual deposit requirement shall not apply; provided, however, that if the guaranteeing organization is sponsoring more than one organization, the net worth requirement shall be increased by a multiple equal to the number of such organizations. This requirement to maintain a deposit in excess of the deposit required of an accident and health insurer shall not apply during any time that the guaranteeing organization maintains a net worth at least equal to the capital and surplus requirements for an accident and health insurer for each organization it sponsors.

     4. All income from deposits shall belong to the depositing organization and shall be paid to it as it becomes available. A health maintenance organization that has made a securities deposit may withdraw the securities deposit or any part thereof, first having deposited, in lieu thereof, a deposit of cash, securities, or any combination of these or other measures of equal amount and value to that withdrawn. Any securities shall be approved by the director before being substituted.

     5. In any year in which an annual deposit is not required of an organization, at its request the director shall reduce the required deposit by one hundred thousand dollars for each two hundred fifty thousand dollars of net worth in excess of the amount that allows it not to make an annual deposit. If the amount of net worth no longer supports a reduction of its required deposit, the organization shall immediately redeposit one hundred thousand dollars for each two hundred fifty thousand dollars of reduction in net worth, provided that its total deposit shall not exceed the maximum required under this section. Notwithstanding any provisions of sections 354.400 to 354.550, the deposit held by the director shall in no case be less than one hundred fifty thousand dollars for a group staff/model or three hundred thousand dollars for an individual practice association model.

     6. Each health maintenance organization that obtains a certificate of authority after September 28, 1983, shall have and maintain a capital account of at least one hundred fifty thousand dollars for a medical group/staff model, or three hundred thousand dollars for an individual practice association in addition to any deposit requirements under this section. The capital account shall be net of any accrued liabilities and be in the form of cash, securities or any combination of these or other measures acceptable to the director.

     7. A certificate of authority shall be denied only after compliance with the requirements of section 354.490.

     354.430. 1. Every enrollee residing in this state is entitled to evidence of coverage. If the enrollee obtains coverage through an insurance policy or a contract issued by a health services corporation, whether by option or otherwise, the insurer or the health services corporation shall issue the evidence of coverage. Otherwise the health maintenance organization shall issue the evidence of coverage.

     2. No evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage, or amendment thereto, has been [filed with] approved by the director. The director shall approve or disapprove the evidence of coverage or amendment thereto in writing within sixty days of filing for the first year after the effective date of this section and within thirty days for all subsequent years.

     3. An evidence of coverage shall contain:

     (1) No provisions or statements which are unjust, unfair, inequitable, misleading, or deceptive, or which encourage misrepresentation, or which are untrue, misleading, or deceptive as defined in subsection 1 of section 354.460; and

     (2) A clear and complete statement, if a contract, or a reasonably complete summary, if a certificate, of:

     (a) The health care services and the insurance or other benefits, if any, to which the enrollee is entitled;

     (b) Any limitations on the services, kind of services, benefits or kinds of benefits to be provided, including any deductible or copayment feature;

     (c) Where and in what manner information is available as to how services may be obtained;

     (d) The total amount of payment for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay with respect to individual contracts; and

     (e) A clear and understandable description of the health maintenance organization's method for resolving enrollee complaints, including the health maintenance organization's toll-free customer service number and the department of insurance's consumer complaint hotline.

     4. Any subsequent change in an evidence of coverage may be made in a separate document issued to the enrollee.

     5. A copy of the form of the evidence of coverage to be used in this state, and any amendment thereto, shall be subject to the filing of subsection 2 of this section unless it is subject to the jurisdiction of the director under the laws governing health insurance or health services corporations, in which event the filing provisions of those laws shall apply.

     354.441. No entity contracting with a health maintenance organization plan for the provision of professional services, health maintenance organization plan, medical group/staff model, independent practice association or any other entity, shall prohibit or restrict any provider from disclosing to any subscriber, enrollee or member any information that such provider deems appropriate regarding the nature of treatment, risks or alternatives thereto, the availability of other therapy, consultation or test, the decision of any plan to authorize or deny services, or the process the plan or any person contracting with the plan uses or proposes to use, to authorize or deny health care services or benefits. Any such prohibition or restriction contained in a contract with a provider entered into after the effective date of this section shall be void and unenforceable.

     354.442. 1. Each enrollee, and upon request each prospective enrollee prior to enrollment, shall be supplied with written disclosure information. In the event of any inconsistency between any separate written disclosure statement and the enrollee contract or evidence of coverage, the terms of the enrollee contract or evidence of coverage shall be controlling. The information to be disclosed in writing shall include at least the following:

     (1) A description of coverage provisions; health care benefits; benefit maximums, including benefit limitations;

     (2) A description of any exclusions of coverage, including the definition of medical necessity used in determining whether benefits will be covered;

     (3) A description of all prior authorization or other requirements for treatments and services;

     (4) A description of utilization review policies and procedures used by the health maintenance organization, including the circumstances under which utilization review will be undertaken; the toll-free telephone number of the utilization review agent; the time-frames under which utilization review decisions must be made for prospective, retrospective and concurrent decisions; the right to reconsideration; the right to an appeal, including the expedited and standard appeals processes and the time-frames for such appeals; the right to designate a representative; a notice that all denials of claims will be made by qualified clinical personnel and that all notices of denials will include information about the basis of the decision; and further appeal rights, if any;

     (5) An explanation of an enrollee's financial responsibility for payment of premiums, coinsurance, copayments, deductibles and any other charge, annual limits on an enrollee's financial responsibility, caps on payments for covered services and financial responsibility for noncovered health care procedures, treatments or services provided within the health maintenance organization;

     (6) An explanation of an enrollee's financial responsibility for payment when services are provided by a health care provider who is not part of the health maintenance organization or by any provider without required authorization or when a procedure, treatment or service is not a covered health care benefit;

     (7) A description of the grievance procedures to be used to resolve disputes between a health maintenance organization and an enrollee, including the right to file a grievance regarding any dispute between an enrollee and a health maintenance organization; the right to file a grievance orally when the dispute is about referrals or covered benefits; the toll-free telephone number which enrollees may use to file an oral grievance; the department of insurance's toll-free consumer complaint hotline; the time-frames and circumstances for expedited and standard grievances; the right to appeal a grievance determination and the procedures for filing such an appeal; the time-frames and circumstances for expedited and standard appeals; the right to designate a representative; a notice that all disputes involving clinical decisions will be made by qualified clinical personnel; and that all notices of determination will include information about the basis of the decision and further appeal rights, if any;

     (8) A description of a procedure for providing care and coverage twenty-four hours a day for emergency services. Such determination shall include a definition of emergency services; notice that emergency services are not subject to prior approval; and shall describe the enrollee's financial and other responsibilities regarding obtaining such services including when such services are received outside the health maintenance organization's service area;

     (9) A description of procedures for enrollees to select and access the health maintenance organization's primary and specialty care providers, including notice of how to determine whether a participating provider is accepting new patients;

     (10) A description of the procedures for changing primary and specialty care providers within the health maintenance organization;

     (11) Notice that an enrollee may obtain a referral to a health care provider outside of the health maintenance organization's network or panel when the health maintenance organization does not have a health care provider with appropriate training and experience in the network or panel to meet the particular health care needs of the enrollee and the procedure by which the enrollee can obtain such referral;

     (12) Notice that an enrollee with a condition which requires ongoing care from a specialist may request a standing referral to such a specialist and the procedure for requesting and obtaining such a standing referral;

     (13) Notice that an enrollee with a life-threatening condition or disease or a degenerative and disabling condition or disease either of which requires specialized medical care over a prolonged period of time may request a specialist responsible for providing or coordinating the enrollee's medical care and the procedure for requesting and obtaining such a specialist;

     (14) Notice that an enrollee with a life-threatening condition or disease or a degenerative and disabling condition or disease either of which requires specialized medical care over a prolonged period of time may request access to a specialty care center and the procedure by which such access may be obtained;

     (15) A description of the mechanisms by which enrollees may participate in the development of the policies of the health maintenance organization;

     (16) Notice of all appropriate mailing addresses and telephone numbers to be utilized by enrollees seeking information or authorization; and

     (17) A listing by specialty, which may be in a separate document that is updated annually, of the names, addresses and telephone numbers of all participating providers, including facilities, and in addition in the case of physicians, board certification.

     2. Each health maintenance organization shall, upon request of an enrollee or prospective enrollee:

     (1) Provide a list of the names, business addresses and official positions of the membership of the board of directors, officers, controlling persons, owners or partners of the health maintenance organization;

     (2) Provide a copy of the most recent annual certified financial statement of the health maintenance organization, including a balance sheet and summary of receipts and disbursements prepared by a certified public accountant;

     (3) Provide a copy of the most recent individual, direct pay enrollee contracts;

     (4) Provide information relating to consumer complaints compiled annually by the department of insurance;

     (5) Provide the procedures for protecting the confidentiality of medical records and other enrollee information;

     (6) Allow enrollees and prospective enrollees to inspect drug formularies used by such health maintenance organization. The health maintenance organization shall also disclose whether individual drugs are included or excluded from coverage to an enrollee or prospective enrollee who requests this information;

     (7) Provide a written description of the organizational arrangements and ongoing procedures of the health maintenance organization's quality assurance program;

     (8) Provide a description of the procedures followed by the health maintenance organization in making decisions about the experimental or investigational nature of individual drugs, medical devices or treatments in clinical trials;

     (9) Provide individual health practitioner affiliations with participating hospitals, if any;

     (10) Upon written request, provide specific written clinical review criteria relating to a particular condition or a disease and, where appropriate, other clinical information which the organization might consider in its utilization review. The health maintenance organization may include with the information a description of how such information will be used in the utilization review process;

     (11) Provide the written application procedures and minimum qualification requirements for health care providers to be considered by the health maintenance organization;

     (12) Provide a description of the procedures followed by the health maintenance organization in making decisions about which drugs to include in the health maintenance organization's drug formulary.

     3. Nothing in this section shall prevent the director from requiring a health maintenance organization to disclose to enrollees additional information as necessary.

     4. Nothing in this section shall prevent a health maintenance organization from changing or updating the materials that are made available to enrollees.

     354.443. Health maintenance organizations shall disclose to the department of insurance all financial arrangements or contractual provisions with review companies or any other health care provider that would limit the type or amount, duration and scope of services offered, restrict or limit referral or treatment to patients, including but not limited to financial incentives to limit, restrict or deny access to or delivery of medical or other services prior to the delivery of such services. Health maintenance organizations may request that such financial arrangements or contractual provisions be deemed proprietary information and not publicly disclosed at the time of the disclosure to the department of insurance. The director shall approve or disapprove the financial arrangements or contractual provisions within sixty days of filing for the first year after the effective date of this section and within thirty days for all subsequent years. The director shall also act on the health maintenance organization's request that such financial arrangements or contractual provisions be deemed proprietary information and not publicly disclosed in part or in full within sixty days of filing for the first year after the effective date of this section and within thirty days for all subsequent years. Health maintenance organizations may request that such financial arrangements or contractual provisions be deemed proprietary information and not publicly disclosed. The director shall approve or disapprove the financial arrangements or contractual provisions within sixty days of filing.

     354.444. 1. Notwithstanding any other provisions of chapter 354, the director may, after a hearing, order a forfeiture to the state of Missouri a sum not to exceed one hundred dollars for each violation by any person willfully violating any provision of sections 354.400 to 354.636 for which no specific punishment is provided, or order a specific punishment in accordance with such sections. Such forfeiture may be recovered by a civil action brought by and in the name of the director of insurance. The civil action may be brought in the county which has venue of an action against the person or corporation under other provisions of law.

     2. Nothing contained in this section shall be construed to prohibit the director and the corporation or its enrollment representative from agreeing to a voluntary forfeiture of the sum mentioned herein without civil proceedings being instituted. Any sum so agreed upon shall be paid into the school fund as provided by article IX, section 7 of the Missouri constitution for other fines and penalties.

     354.470. 1. The director may suspend [or], revoke or place conditions or restrictions on any certificate of authority issued to a health maintenance organization under sections 354.400 to 354.550 if he finds that any of the following conditions exist:

     (1) The health maintenance organization is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in any other information submitted under section 354.405, unless amendments to such submissions have been filed with and approved by the director;

     (2) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of section 354.430;

     (3) The health maintenance organization does not provide nor arrange for basic health care services;

     (4) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;

     (5) The health maintenance organization has failed to implement a mechanism affording the enrollees an opportunity to participate in matters of policy and operation as required under section 354.420;

     (6) The health maintenance organization has failed to implement the complaint system required by section 354.450 in a manner designed to reasonably resolve valid complaints;

     (7) The health maintenance organization has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner;

     (8) The continued operation of the health maintenance organization would be hazardous to its enrollees;

     (9) The person operating the health maintenance organization is in violation of the provisions of sections 375.930 to 375.948, RSMo, except to the extent that the director has determined that the nature of health maintenance organizations renders the application of such sections clearly inappropriate; notwithstanding the foregoing, paragraph (b) of subdivision (11) of section 375.936, RSMo, shall not apply to health maintenance organizations;

     (10) The health maintenance organization has otherwise failed to substantially comply with sections 354.400 to 354.550.

     2. A certificate of authority shall be suspended [or], revoked or be subject to conditions or restrictions only after compliance with the requirements of section 354.490.

     3. When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of such suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever.

     4. When the certificate of authority of a health maintenance organization is revoked, such health maintenance organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of such organization. It shall engage in no further advertising or solicitation whatsoever. The director may, by written order, permit such further operation of the health maintenance organization as he may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage.

     354.490. 1. When the director has cause to believe that grounds for the denial of an application for a certificate of authority exist, [or] that grounds for the suspension or revocation of a certificate of authority exist, [he] or that grounds for the imposition of restrictions or conditions on a certificate of authority exist, the director shall notify the health maintenance organization in writing, specifically stating the grounds for denial, suspension, [or] revocation, or conditions or restrictions and fixing a time of at least twenty days thereafter for a hearing on the matter.

     2. After such hearing, or upon the failure of the health maintenance organization to appear at such hearing, the director shall take action as is deemed advisable, on the basis of written findings, which shall be mailed to the health maintenance organization. The action of the director shall be subject to review by the circuit court having jurisdiction. The court may, in disposing of the issue before it, modify, affirm, or reverse the order of the director in whole or in part.

     3. The provisions of chapter 536, RSMo, shall apply to proceedings under this section to the extent they are not in conflict with subsections 1 and 2 of this section.

     354.505. 1. Except as otherwise provided in section 192.068, RSMo, sections 354.400 to [354.550] 354.636, sections 374.500 to 374.515, RSMo, and sections 376.1350 to 376.1390, RSMo, provisions of the insurance law and provisions of health services corporation laws shall not be applicable to any health maintenance organization granted a certificate of authority under sections 354.400 to 354.550. This provision shall not apply to an insurer or health services corporation licensed and regulated pursuant to the insurance laws or the health services corporation laws of this state except with respect to its health maintenance organization activities authorized and regulated pursuant to sections 354.400 to 354.550.

     2. Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its duly authorized representatives, shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.

     [3. Any health maintenance organization authorized under sections 354.400 to 354.550 shall not be deemed to be practicing medicine and shall be exempt from the provisions of chapter 334, RSMo.]

     354.515. 1. Any data or information pertaining to the diagnosis, treatment, or health of any enrollee or applicant obtained from such person, or from any provider, by any health maintenance organization shall be held in confidence and shall not be disclosed to any person except as follows:

     (1) To the extent that it may be necessary to carry out the purposes of sections 354.400 to 354.550;

     (2) Upon the express consent of the enrollee or applicant;

     (3) Pursuant to statute or court order for the production of evidence or the discovery thereof;

     (4) In the event of a claim or litigation between such person and the health maintenance organization wherein such data or information is pertinent. A health maintenance organization shall be entitled to claim any statutory privileges against such disclosure which the provider who furnishes such information to the health maintenance organization is entitled to claim, but no such claim or privilege against disclosure may be made against the director by such health maintenance organization.

     2. Every health maintenance organization shall establish and maintain procedures to ensure that all mental health records of enrollees remain confidential. Such procedures and any subsequent amendments thereto shall be filed annually with the director. The mental health records of enrollees shall not be available to other health care providers in the plan, including primary care providers, without written permission from the enrollee, unless it is medically necessary as determined by the attending physician and the health maintenance organization.

     354.535. [In the event that] 1. If a pharmacy, operated by or contracted with by a health maintenance organization, is closed or is unable to provide health care services to an enrollee in an emergency, a pharmacist may take an assignment of such enrollee's right to reimbursement, if the policy or contract provides for such reimbursement, for those goods or services provided to [a member] an enrollee of a health maintenance organization. No health maintenance organization shall refuse to pay the [pharmacists] pharmacist any payment due the enrollee under the terms of the policy or contract.

     2. A health carrier in all contracts and arrangements entered into with any pharmacist or pharmaceutical provider at retail or any covered person in this state on or after the effective date of this bill shall be prohibited from:

(1) Specifying a co-payment amount to be paid by a covered person which is not identical regardless of pharmacy provider; and

(2) Setting a limit on the quantity of drugs which a covered person may obtain at any one time which differs by pharmacy provider.

     3. No health maintenance organization shall confer financial, contractual or other benefits, by way of policy or procedure, on mail order pharmacies that are not offered to other pharmacies in the health maintenance organization's network.

     354.600. For purposes of sections 354.600 to 354.636 the following terms shall mean:

     (1) "Covered benefits" or "benefits", those health care services to which a covered person is entitled under the terms of a health benefit plan;

     (2) "Covered person", a policyholder, subscriber, enrollee or other individual participating in a health benefit plan;

     (3) "Director", the director of the department of insurance;

     (4) "Emergency", a medical condition, the onset of which is sudden, of recent onset, or involves the exacerbation of a chronic condition, that manifests itself by symptoms of sufficient severity, which may include severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention to result in:

     (a) Placing the person's health in significant jeopardy;

     (b) Serious impairment to a bodily function;

     (c) Serious dysfunction of any bodily organ or part;

     (d) Inadequately controlled pain; or

     (e) With respect to a pregnant woman who is having contractions:

     a. That there is inadequate time to effect a safe transfer to another hospital before delivery; or

     b. That transfer to another hospital may pose a threat to the health or safety of the woman or unborn child;

     (5) "Emergency services", health care services that are provided in a licensed hospital's emergency facility by an appropriate provider to the extent that they are required to evaluate and treat an emergency medical condition until the condition is stabilized;

     (6) "Facility", an institution providing health care services or a health care setting, including but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing facilities, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings;

     (7) "Health benefit plan", a policy, contract, certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services;

     (8) "Health care professional", a physician or other health care practitioner licensed, accredited or certified by the state of Missouri to perform specified health services;

     (9) "Health care provider" or "provider", a health care professional or a facility;

     (10) "Health care services", services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease;

     (11) "Health carrier", a health maintenance organization established pursuant to sections 354.400 to 354.550, RSMo;

     (12) "Health indemnity plan", a health benefit plan that is not a managed care plan;

     (13) "Intermediary", a person authorized to negotiate and execute provider contracts with health carriers on behalf of health care providers or on behalf of a network;

     (14) "Managed care plan", a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with or employed by the health carrier;

     (15) "Network", the group of participating providers providing services to a managed care plan;

     (16) "Participating provider", a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments or deductibles, directly or indirectly from the health carrier;

     (17) "Person", an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the foregoing; and

     (18) "Primary care professional", a participating health care professional designated by the health carrier to supervise, coordinate or provide initial care or continuing care to a covered person, and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the covered person.

     354.603. 1. A health carrier shall maintain a network that is sufficient in numbers and types of providers to assure that all services to covered persons will be accessible without unreasonable delay. In the case of emergency services, covered persons shall have access twenty-four hours per day, seven days per week. Sufficiency shall be determined by the director in accordance with the requirements of this section and by reference to any reasonable criteria, including but not limited to: provider-covered person ratios by specialty; primary care provider-covered person ratios; geographic accessibility; waiting times for appointments with participating providers; hours of operation; and the volume of technological and specialty services available to serve the needs of covered persons requiring technologically advanced or specialty care.

     (1) In any case where the health carrier has an insufficient number or type of participating provider to provide a covered benefit, the health carrier shall ensure that the covered person obtains the covered benefit at no greater cost to the covered person than if the benefit were obtained from participating providers, or shall make other arrangements acceptable to the director.

     (2) The health carrier shall establish and maintain adequate arrangements to ensure reasonable proximity of participating providers, including pharmacists, to the business or personal residence of covered persons. In determining whether a health carrier has complied with this provision, the director shall give due consideration to the relative availability of health care providers in the service area under consideration.

     (3) A health carrier shall monitor, on an ongoing basis, the ability, clinical capacity, financial capability and legal authority of its providers to furnish all contracted benefits to covered persons.

     (4) A health carrier shall make its entire network available to all covered persons, for the services contractually agreed upon, unless a covered person has agreed in writing to a different or reduced network. A copy of all such agreements shall be filed with the director.

     2. Beginning July 1, 1998, a health carrier shall file with the director for approval an access plan meeting the requirements of sections 354.600 to 354.636 for each of the managed care plans that the carrier offers in this state. The health carrier may request the director to deem sections of the access plan as proprietary or competitive information that shall not be made public. For the purposes of this section, information is proprietary or competitive if revealing the information would cause the health carrier's competitors to obtain valuable business information. The health carrier shall make the access plans, absent proprietary information, available to any interested party upon request. The carrier shall prepare an access plan prior to offering a new managed care plan, and shall update an existing access plan whenever it makes any change as defined by the director to an existing managed care plan. The director shall approve or disapprove the access plan, or any subsequent alterations to the access plan, within sixty days for the first year after the effective date of this section and within thirty days for all subsequent years. The access plan shall describe or contain at least the following:

     (1) The health carrier's network;

     (2) The health carrier's procedures for making referrals within and outside its network;

     (3) The health carrier's process for monitoring and assuring on an ongoing basis the sufficiency of the network to meet the health care needs of enrollees of the managed care plan;

     (4) The health carrier's methods for assessing the health care needs of covered persons and their satisfaction with services;

     (5) The health carrier's method of informing covered persons of the plan's services and features, including but not limited to, the plan's grievance procedures, its process for choosing and changing providers, and its procedures for providing and approving emergency and specialty care;

     (6) The health carrier's system for ensuring the coordination and continuity of care for covered persons referred to specialty physicians, for covered persons using ancillary services, including social services and other community resources, and for ensuring appropriate discharge planning;

     (7) The health carrier's process for enabling covered persons to change primary care professionals;

     (8) The health carrier's proposed plan for providing continuity of care in the event of contract termination between the health carrier and any of its participating providers, in the event of a reduction in service area or in the event of the health carrier's insolvency or other inability to continue operations. The description shall explain how covered persons will be notified of the contract termination, reduction in service area or the health carrier's insolvency or other modification or cessation of operations, and transferred to other providers in a timely manner; and

     (9) Any other information required by the director to determine compliance with the provisions of sections 354.600 to 354.636.

     354.606. 1. A health carrier shall establish a mechanism by which the participating provider will be notified on an ongoing basis of the specific covered health services for which the provider will be responsible, including any limitations or conditions on services.

     2. Every contract between a health carrier and a participating provider shall set forth a hold harmless provision specifying protection for covered persons. This requirement shall be met by including a provision substantially similar to the following:

     "Provider agrees that in no event, including but not limited to nonpayment by the health carrier or intermediary, insolvency of the health carrier or intermediary, or breach of this agreement, shall the provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a covered person or a person, other than the health carrier or intermediary, acting on behalf of the covered person for services provided pursuant to this agreement. This agreement does not prohibit the provider from collecting coinsurance, deductibles or copayments, as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to covered persons. Nor does this agreement prohibit a provider, except for a health care professional who is employed full-time on the staff of a health carrier and has agreed to provide service exclusively to that health carrier's covered persons and no others, and a covered person from agreeing to continue services solely at the expense of the covered person, as long as the provider has clearly informed the covered person that the health carrier may not cover or continue to cover a specific service or services. Except as provided herein, this agreement does not prohibit the provider from pursuing any available legal remedy."

     3. Every contract between a health carrier and a participating provider shall set forth that in the event of a health carrier or intermediary insolvency or other cessation of operations, covered services to covered persons will continue through the period for which a premium has been paid to the health carrier on behalf of the covered person or until the covered person's discharge from an inpatient facility, whichever time is greater.

     4. The contract provisions that satisfy the requirements of subsections 2 and 3 of this section shall be construed in favor of the covered person, shall survive the termination of the contract regardless of the reason for termination, including the insolvency of the health carrier, and shall supersede any oral or written contrary agreement between a provider and a covered person or the representative of a covered person if the contrary agreement is inconsistent with the hold harmless and continuation of covered services provisions required by subsections 2 and 3 of this section.

     5. In no event shall a participating provider collect or attempt to collect from a covered person any money owed to the provider by the health carrier. Failure of a health carrier to make timely payment of amounts owed to a provider in accordance with the provider's contract shall constitute an unfair claims settlement practice subject to sections 375.1000 to 375.1018, RSMo.

     6. (1) Health carriers shall develop selection standards for participating primary care professionals and each participating health care professional specialty. The standards shall be in writing and shall be used in determining the selection of health care professionals by the health carrier, its intermediaries and any provider networks with which it contracts. Selection criteria shall not be established in a manner:

     (a) That would allow a health carrier to avoid high-risk populations by excluding providers because they are located in geographic areas that contain populations presenting a risk of higher than average claims, losses or health services utilization; or

     (b) That would exclude providers because they treat or specialize in treating populations presenting a risk of higher than average claims, losses or health services utilization.

     (2) Paragraphs (a) and (b) of subdivision (1) of this subsection shall not be construed to prohibit a health carrier from declining to select a provider who fails to meet the other legitimate selection criteria of the health carrier developed in compliance with sections 354.600 to 354.636.

     (3) The provisions of sections 354.600 to 354.636 do not require a health carrier, its intermediaries or the provider networks with which it contracts, to employ specific providers or types of providers, or to contract with or retain more providers or types of providers than are necessary to maintain an adequate network.

     7. A health carrier shall annually file its selection standards for participating providers with the director.

     8. A health carrier shall notify participating providers of the providers' responsibilities with respect to the health carrier's applicable administrative policies and programs, including but not limited to payment terms, utilization review, quality assessment and improvement programs, credentialing, grievance procedures, data reporting requirements, confidentiality requirements and any applicable federal or state programs.

     9. A health carrier shall not offer an inducement under the managed care plan to a provider to provide less than medically necessary services to a covered person.

     10. A health carrier shall not prohibit a participating provider from advocating on behalf of covered persons within the utilization review or grievance processes established by the health carrier or a person contracting with the health carrier.

     11. A health carrier shall require a provider to make health records available to appropriate state and federal authorities involved in assessing the quality of care or investigating the grievances or complaints of covered persons, and to comply with the applicable state and federal laws related to the confidentiality of medical or health records.

     12. The rights and responsibilities of a provider under a contract between a health carrier and a participating provider shall not be assigned or delegated by the provider without the prior written consent of the health carrier.

     13. A health carrier is responsible for ensuring that a participating provider furnishes covered benefits to all covered persons without regard to the covered person's enrollment in the plan as a private purchaser of the plan or as a participant in publicly financed programs of health care services. This requirement does not apply to circumstances when the provider should not render services due to limitations arising from lack of training, experience, skill or licensing restrictions.

     14. A health carrier shall notify the participating providers of their obligations, if any, to collect applicable coinsurance, copayments or deductibles from covered persons pursuant to the evidence of coverage, or of the providers' obligations, if any, to notify covered persons of their personal financial obligations for noncovered services.

     15. A health carrier shall not penalize a provider because the provider, in good faith, reports to state or federal authorities any act or practice by the health carrier that could jeopardize patient health or welfare.

     16. A health carrier shall establish a mechanism by which the participating providers may determine in a timely manner whether or not a person is covered by the carrier.

     17. A health carrier shall establish procedures for resolution of administrative, payment or other disputes between providers and the health carrier.

     18. A contract between a health carrier and a provider shall not contain definitions or other provisions that conflict with the definitions or provisions contained in the managed care plan or sections 354.600 to 354.636.

     19. A health carrier shall ensure that the medical director of the health carrier is responsible for the continuity of health care services for all covered persons.

     20. A health carrier shall be prohibited, when selecting among providers of health services for membership in the provider network, from discriminating against any health care professional on the basis of such professional's licensure or category of service. In selecting health care providers, a health carrier's provider networks shall provide a sufficient number and range of health professionals, specialties and practice settings to assure adequate access to the comprehensive benefit package. Selection criteria used by provider networks shall include the number, capacity and geographic distribution of all health professionals within the designated service area.

     354.609. 1. A health carrier and a participating provider shall provide at least sixty days written notice to each other before terminating the contract without cause. The written notice shall include an explanation of why the contract is being terminated. The health carrier shall provide written notice within thirty working days of receipt or issuance of a notice of termination to all covered persons who are patients seen on a regular basis by the provider whose contract is terminating, irrespective of whether the termination was for cause or without cause. Where a contract termination involves a primary care professional, all covered persons who are patients of that primary care professional shall be notified. Within fifteen working days of the date that the provider either gives or receives notice of termination, the provider shall supply the health carrier with a list of those patients of the provider that are covered by a plan of the health carrier.

     2. (1) A health carrier shall not terminate a contract with a health care professional unless the health carrier provides to the health care professional a written explanation of the reasons for the proposed contract termination and an opportunity for a review or hearing as hereinafter provided. This subsection shall not apply in cases involving imminent harm to patient care, a determination of fraud, or a final disciplinary action by a state licensing board or other governmental agency that impairs the health care professional's ability to practice.

     (2) The notice of the proposed contract termination provided by the health carrier to the health care professional shall include:

     (a) The reasons for the proposed action;

     (b) Notice that the health care professional has the right to request a hearing or review, at the professional's discretion, before a panel appointed by the health carrier;

     (c) A time limit of not less than thirty days within which a health care professional may request a hearing; and

     (d) A time limit for a hearing date which must be held within thirty days after the date of receipt of a request for a hearing.

     (3) The hearing panel shall be comprised of at least three persons appointed by the health carrier. At least one person on such panel shall be a clinical peer in the same discipline and the same or similar specialty as the health care professional under review. The hearing panel may consist of more than three persons, provided however that the number of clinical peers on such panel shall constitute one-third or more of the total membership of the panel.

     (4) The hearing panel shall render a decision on the proposed action within fifteen days after a hearing. Such decision shall include reinstatement of the health care professional by the health carrier, provisional reinstatement subject to conditions set forth by the health carrier or termination of the health care professional. Such decision shall be provided in writing to the health care professional.

     (5) A decision by the hearing panel to terminate a health care professional shall be effective not less than thirty days after the receipt by the health care professional of the hearing panel's decision.

     (6) No termination shall be effective earlier than sixty days from the receipt of the notice of termination.

     3. Either party to a contract may exercise a right of nonrenewal at the expiration of the contract period set forth therein occurring after the contract has been in effect for at least one year, upon sixty days' notice to the other party; provided, however, that any nonrenewal shall not constitute a termination for purposes of this section.

     4. A health carrier shall develop and implement policies and procedures to ensure that health care professionals are regularly informed of information maintained by the health carrier to evaluate the performance or practice of the health care professional. The health carrier shall consult with health care professionals in developing methodologies to collect and analyze health care professional profiling data. The health carrier shall provide any such information and profiling data and analysis to health care professionals. Such information, data or analysis shall be provided on a periodic basis appropriate to the nature and amount of data and the volume and scope of services provided. Any profiling data used to evaluate the performance or practice of a health care professional shall be measured against stated criteria and an appropriate group of health care professionals using similar treatment modalities serving a comparable patient population. Upon presentation of such information or data, each health care professional shall be given the opportunity to discuss the unique nature of the health care professional's patient population which may have a bearing on the health care professional's profile and to work cooperatively with the health carrier to improve performance.

     5. No health carrier shall terminate a contract or employment, or refuse to renew a contract, solely because a health care provider has:

     (1) Advocated on behalf of a covered person;

     (2) Filed a complaint against the health carrier;

     (3) Appealed a decision of the health carrier;

     (4) Provided information or filed a report with the department of insurance; or

     (5) Requested a hearing or review pursuant to this section.

     6. A health carrier shall give providers at least thirty days to review managed care contracts.

     354.612. 1. If a covered person's health care provider leaves a health carrier's network of providers for reasons other than those for which the provider would not be eligible to receive a hearing pursuant to section 354.609, the health carrier shall permit the covered person to continue an ongoing course of treatment with the covered person's current health care provider during a transitional period:

     (1) Of up to ninety days from the date of notice to the covered person of the provider's disaffiliation from the health carrier's network; or

     (2) If the covered person has entered the second trimester of pregnancy at the time of the provider's disaffiliation, for a transitional period that includes the provision of post-partum care directly related to the delivery.

     2. Notwithstanding the provisions of subsection 1 of this section, such care shall be authorized by the health carrier during the transitional period only if the health care provider agrees:

     (1) To continue to accept reimbursement from the health carrier at the rates applicable prior to the start of the transitional period as payment in full;

     (2) To adhere to the health carrier's quality assurance requirements and to provide to the health carrier necessary medical information related to such care; and

     (3) To otherwise adhere to the health carrier's policies and procedures, including but not limited to procedures regarding referrals and obtaining pre-authorization and a treatment plan approved by the health carrier.

     3. If a newly covered person whose health care provider is not a member of the health carrier's provider network enrolls in the health carrier's health benefit plan, the health carrier shall permit the covered person to continue an ongoing course of treatment with the covered person's current health care provider during a transitional period of up to sixty days from the effective date of enrollment if:

     (1) The covered person has a life-threatening disease or condition or a degenerative and disabling disease or condition; or

     (2) The covered person has entered the second trimester of pregnancy at the effective date of enrollment, in which case the transitional period shall include the provision of post-partum care directly related to the delivery.

     4. If a covered person elects to continue to receive care from such health care provider pursuant to subsection 2 of this section, such care shall be authorized by the health carrier for the transitional period only if the health care provider agrees to:

     (1) Accept reimbursement from the health carrier at rates established by the health carrier as payment in full. These rates shall be no more than the level of reimbursement applicable to similar providers within the health carrier's network for such services;

     (2) Adhere to the carrier's quality assurance requirements and agrees to provide to the health carrier necessary medical information related to such care; and

     (3) Otherwise adhere to the health carrier's policies and procedures including, but not limited to, procedures regarding referrals and obtaining pre-authorization and a treatment plan approved by the health carrier. In no event shall this subsection be construed to require a health carrier to provide coverage for benefits not otherwise covered or to diminish or impair pre-existing condition limitations contained within the covered person's contract.

     354.615. 1. If a health carrier determines that it does not have a health care provider with appropriate training and experience in its panel or network to meet the particular health care needs of a covered person, the health carrier shall make a referral to an appropriate provider, pursuant to a treatment plan approved by the health carrier in consultation with the primary care provider, the non-participating provider and the covered person or covered person's designee, at no additional cost to the covered person beyond what the covered person would otherwise pay for services received within the network.

     2. A health carrier shall have a procedure by which a covered person who needs ongoing care from a specialist may receive a standing referral to such specialist. If the health carrier, or the primary care provider in consultation with the medical director of the health carrier and an appropriate specialist, determines that such a standing referral is warranted, the carrier shall make such a referral to a specialist. In no event shall a health carrier be required to permit a covered person to elect to have a non-participating specialist, except pursuant to the provisions of subsection 1 of this section. Such referral shall be pursuant to a treatment plan approved by the health carrier in consultation with the primary care provider, the specialist, and the covered person or the covered person's designee. Such treatment plan may limit the number of visits or the period during which such visits are authorized and may require the specialist to provide the primary care provider with regular updates on the specialty care provided, as well as all necessary medical information.

     3. A health carrier shall have a procedure by which a new covered person upon enrollment, or a covered person upon diagnosis, with (i) a life-threatening condition or disease or (ii) a degenerative and disabling condition or disease, either of which requires specialized medical care over a prolonged period of time, may receive a referral to a specialist with expertise in treating the life-threatening or degenerative and disabling disease or condition who shall be responsible for and capable of providing and coordinating the covered person's primary and specialty care. If the health carrier, or primary care provider in consultation with a medical director of the health carrier and an appropriate specialist, determines that the covered person's care would most appropriately be coordinated by such a specialist, the health carrier shall refer the covered person to such specialist. In no event shall a health carrier be required to permit a covered person to elect to have a non-participating specialist, except pursuant to the provisions of subsection 1 of this section. Such referral shall be pursuant to a treatment plan approved by the health carrier, in consultation with the primary care provider if appropriate, the specialist, and the covered person or the covered person's designee. Such specialist shall be permitted to treat the covered person without a referral from the covered person's primary care provider and may authorize such referrals, procedures, tests and other medical services as the covered person's primary care provider would otherwise be permitted to provide or authorize, subject to the terms of the treatment plan. If a health carrier refers a covered person to a non-participating provider, services provided pursuant to the approved treatment plan shall be provided at no additional cost to the covered person beyond what the covered person would otherwise pay for services received within the network.

     4. A health carrier shall have a procedure by which a covered person with (i) a life-threatening condition or disease or (ii) a degenerative and disabling condition or disease, either of which requires specialized medical care over a prolonged period of time, may receive a referral to a specialty care center with expertise in treating the life-threatening or degenerative and disabling disease or condition. If the health carrier, or the primary care provider or a specialist designated pursuant to this section, in consultation with a medical director of the health carrier, determines that the covered person's care would most appropriately be provided by such a specialty care center, the health carrier shall refer the covered person to such center. In no event shall a health carrier be required to permit a covered person to elect to have a non-participating specialty care center, unless the health carrier does not have an appropriate specialty care center to treat the covered person's disease or condition within its network. Such referral shall be pursuant to a treatment plan developed by the specialty care center and approved by the health carrier, in consultation with the primary care provider, if any, or a specialist designated pursuant to subsection 3 of this section, and the covered person or the covered person's designee. If a health carrier refers a covered person to a specialty care center that does not participate in the health carrier's network, services provided pursuant to the approved treatment plan shall be provided at no additional cost to the covered person beyond what the covered person would otherwise pay for services received within the network. For purposes of this subsection, a specialty care center shall mean only such centers as are accredited or designated by an agency of the state or federal government or by a voluntary national health organization as having special expertise in treating the life-threatening disease or condition or degenerative and disabling disease or condition for which it is accredited or designated.

     354.618. 1. A health carrier shall have a procedure by which a covered person can seek the health care services of an eye care provider or a dental care provider at least twice without first obtaining prior approval from the covered person's primary care provider if (i) the benefits are covered under the covered person's health benefit plan, and (ii) the eye care provider or dental care provider is a member of the health carrier's network. In no event shall a health carrier be required to permit a covered person to have health care services delivered by a nonparticipating eye care provider or dental care provider. An eye care provider or dental care provider who delivers health care services directly to a covered person shall report such visit and health care services provided to the covered person's primary care provider. For the purposes of this section, an eye care provider may be either an optometrist licensed pursuant to chapter 336, RSMo, or a physician who specializes in ophthalmologic medicine. For the purposes of this section, a dental care provider may be either a dentist licensed pursuant to chapter 332, RSMo, or a physician who specializes in orthodontic medicine.

     2. A health carrier may require a covered person to obtain a referral from the primary care physician, if such covered person requires more than two annual visits with an eye care provider or a dental care provider.

     354.621. 1. Intermediaries and participating providers with whom they contract shall comply with all the applicable requirements of sections 354.600 to 354.636.

     2. A health carrier's statutory responsibility to monitor the offering of covered benefits to covered persons shall not be delegated or assigned to the intermediary.

     3. If applicable, an intermediary shall transmit utilization documentation and claims paid documentation to the health carrier. The carrier shall monitor the timeliness and appropriateness of payments made to providers and health care services received by covered persons.

     4. If applicable, an intermediary shall maintain the books, records, financial information and documentation of services provided to covered persons at its principal place of business in the state and preserve them for five years in a manner that facilitates regulatory review.

     5. An intermediary shall allow a health carrier or the director access to the intermediary's books, records, financial information and any documentation of services provided to covered persons, as necessary to determine compliance with sections 354.600 to 354.636.

     6. A health carrier shall have the right, in the event of the intermediary's insolvency, to require the assignment to the health carrier of the provisions of a provider's contract addressing the provider's obligation to furnish covered services.

     354.624. 1. Beginning January 1, 1998, a health carrier shall file with the director all contract forms, including compensation terms, proposed for use with its participating providers and intermediaries.

     2. A health carrier shall submit any material changes to a contract form to the director for approval prior to use.

     3. The director shall approve or disapprove the contract form or change to a contract form in writing within sixty days of filing for the first year after the effective date of this section and within thirty days for all subsequent years.

     4. The health carrier shall maintain provider and intermediary contracts at its principal place of business in the state, or the health carrier shall have access to all contracts and provide copies to facilitate regulatory review upon twenty days prior written notice from the director or at the time of any examination.

     354.627. 1. The executing of a contract by a health carrier shall not relieve the health carrier of its liability to any person with whom it has contracted for the provision of services, nor of its responsibility for compliance with the law or applicable regulations.

     2. All contracts shall be in writing and may be subject to review by the department of insurance.

     3. All contracts shall comply with applicable requirements of the law and applicable regulations.

     354.633. The director shall carry out the provisions of sections 354.600 to 354.636.

     354.636. All provider and intermediary contracts delivered, issued for delivery, continued or renewed on or after March 1, 1998, shall comply with sections 354.600 to 354.636 unless otherwise provided by sections 354.600 to 354.636.

     374.500. As used in sections 374.500 to 374.515, the following terms mean:

     (1) "Certificate", a certificate of registration granted by the department of insurance to a utilization review agent;

     (2) "Director", the director of the department of insurance;

     (3) "Enrollee", an individual who has contracted for or who participates in coverage under a health insurance policy, an employee welfare benefit plan, a health services corporation plan or any other benefit program providing payment, reimbursement or indemnification for health care costs for himself or eligible dependents or both himself and eligible dependents. The term "enrollee" shall not include an individual who has health care coverage pursuant to a liability insurance policy, workers' compensation insurance policy, or medical payments insurance issued as a supplement to a liability policy;

     (4) "Provider of record", the physician or other licensed practitioner identified to the utilization review agent as having primary responsibility for the care, treatment and services rendered to an enrollee;

     (5) "Utilization review", [a system for prospective and concurrent review of the necessity and appropriateness in the allocation of health care resources and services given or proposed to be given to an enrollee within this state. "Utilization review" shall not include elective requests for clarification of coverage] a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning or retrospective review. Utilization review shall not include elective requests for clarification of coverage;

     (6) "Utilization review agent", any person or entity performing utilization review, except:

     (a) An agency of the federal government;

     (b) An agent acting on behalf of the federal government, but only to the extent that the agent is providing services to the federal government; or

     (c) [A health maintenance organization authorized pursuant to sections 354.400 to 354.550, RSMo, performing utilization review for its own enrollees;

     (d)] Any individual person employed or used by a utilization review agent for the purpose of performing utilization review services, including, but not limited to, individual nurses and physicians, unless such individuals are providing utilization review services to the applicable benefit plan, pursuant to a direct contractual relationship with the benefit plan;

     [(e)] (d) An employee health benefit plan that is self-insured and qualified under the federal Employee Retirement Income Security Act of 1974, as amended;

     [(f)] (e) A property-casualty insurer or an employee or agent working on behalf of a property-casualty insurer;

     (7) "Utilization review plan", a summary of the utilization review procedures of a utilization review agent.

     374.507. [1.] In conjunction with the application, the utilization review agent shall submit additional information as required by [that] the department of insurance [requires including:

     (1) A utilization review plan that includes:

     (a) A summary of the process whereby utilization standards and procedures are established, modified and updated;

     (b) The provisions by which patients, physicians or hospitals may seek reconsideration or appeal of adverse decisions by the utilization review agent;

     (2) The type and qualifications of the personnel either employed or under contract to perform the utilization review;

     (3) The procedures and policies to ensure that a representative of the utilization review agent is reasonably accessible to patients and providers five days a week during normal business hours in this state;

     (4) The policies and procedures to ensure that all applicable state and federal laws to protect the confidentiality of individual medical records are followed;

     (5) A copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan.

     2. Any material changes in the information filed in accordance with this section shall be filed with the director biannually].

     374.510. 1. All utilization review agents shall meet the [following] minimum requirements[:

     (1) Utilization review agents shall provide enrollees and providers with information of the utilization review agents' requirements, unless such information is provided by the insurer, health services corporation, employer or labor union;

     (2) Upon request, employees of utilization review agents shall make available to any properly identified enrollee or provider of record the corporate name and address of the utilization review entity employing his services;

     (3) Utilization review agents shall maintain and make available a written description of the appeal procedure by which enrollees or the provider of record may seek review of determinations by the utilization review agent. The appeal procedure shall provide for the following:

     (a) On appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate shall be made by a licensed physician in the same or a similar general specialty as typically manages the medical condition, procedure or treatment under discussion and is reasonably available as appropriate to review the case, other than the physician who made the initial determination;

     (b) Utilization review agents shall complete the adjudication of appeals of determinations not to certify admissions, services and procedures no later than thirty days from the date the appeal is filed, and the receipt of all information necessary to complete the appeal;

     (c) Utilization review agents shall also provide for an expedited appeals process for emergency or life-threatening situations. Utilization review agents shall complete the adjudication of such expedited appeals within two business days of the date the appeal is filed, and the receipt of all information necessary to complete the appeal;

     (4) Utilization review agents shall make staff available by toll-free telephone, at least forty hours per week during normal business hours;

     (5) Utilization review agents shall have a phone system capable of accepting or recording or both accepting and recording incoming phone calls during other than normal business hours, and shall respond to these calls within two business days;

     (6) Utilization review agents shall comply with all applicable laws to protect confidentiality of enrollee medical records;

     (7) Utilization review agents shall allow a minimum of forty-eight hours following an emergency admission, service or procedure for an enrollee or his representative to notify the utilization review agent and request certification or continuing treatment for that condition. A utilization review agent shall permit immediate hospitalization of any enrollee for whom the physician of record determines the admission to be of a life-threatening emergency, so long as medical necessity is promptly documented. Nothing in sections 374.500 to 374.515 requires the utilization review agent or any other party to authorize payment for any services provided during that forty-eight-hour period, regardless of medical necessity, if those services do not otherwise constitute covered benefits.

     2. Notification of a determination by the utilization review agent shall be mailed or otherwise communicated to the provider of record or the enrollee, or both the provider of record and the enrollee, or other appropriate individual, within two business days of the receipt of the request for determination, and the receipt of all information necessary to complete the review.

     3. Any determination by a utilization review agent as to the necessity or appropriateness of an admission, service or procedure shall be reviewed by a physician or determined in accordance with standards or guidelines approved by a physician. Any determination not to certify an admission, service or procedure shall be made by a licensed physician.

     4. Any notification of a determination not to certify an admission, service or procedure shall include:

     (a) The principal reason for the determination; and

     (b) The procedures to initiate an appeal of the determination.

     5. Hospitals and physicians shall cooperate with the reasonable efforts of utilization review agents to ensure that all necessary patient information is available in a timely fashion by phone during normal business hours. Procedures shall be established by hospitals and physicians to allow on-site review of medical records by the utilization review agent] set forth in sections 376.1350 to 376.1390.

     6. All utilization review agents certified before September 1, 1997, shall meet the requirements set forth in sections 376.1350 to 376.1390 by January 1, 1998, or such certification shall be deemed invalid.

     376.381. 1. For purposes of this section [and section 376.382, the term "recognized mental illness" shall include those conditions classified as "mental disorders" in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, but shall not include mental retardation] the following terms shall mean:

     (1) "Medical coverage", inpatient hospitalization and outpatient medication visits;

     (2) "Recognized mental illness", those conditions classified as "mental disorders" in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, but shall not include mental retardation;

     (3) "Serious mental illness", any mental disorder that current medical science affirms is caused by a biological disorder of the brain and that substantially limits the life activities of the person with the illness. The term includes, but is not limited to:

     (a) Schizophrenia;

     (b) Schizoaffective disorder;

     (c) Delusional disorder;

     (d) Bipolar affective disorder;

     (e) Major depression;

     (f) Obsessive compulsive disorder;

     (g) Pervasive developmental disorders;

     (h) Autism.

     2. After August 28, [1996] 1997, every insurance company, health services corporation and health maintenance organization doing business in Missouri shall offer [to each policyholder or contract holder of a] in each medical expense policy or contract coverage for expenses arising from psychiatric services for a recognized mental illness and professional counseling as defined by section 337.500, RSMo, which coverage shall, in addition to subsection 2 of section 376.811, at least meet the following minimum requirements:

     (1) In the case of policies or contracts which provide benefits for expenses as an inpatient in a general hospital, benefits for inpatient treatment for a recognized mental illness shall be the same as for any other illness[, except that benefits may be limited, but benefits shall be available for at least thirty days in any policy or contract benefit period];

     (2) In the case of policies or contracts which provide benefits for outpatient expenses, benefits shall apply to the therapeutic care and treatment of a recognized mental illness when prescribed by a licensed physician specializing in the treatment of mental illness and rendered in a psychiatric residential treatment center accredited by the Joint Commission on Accreditation of Hospitals on either an inpatient or outpatient basis. Such benefits shall be payable within the terms of the policy or contract, notwithstanding the policy or contract definition of hospital, to the extent of [not less than fifty percent of the reasonable and customary charges for such services and up to a maximum benefit of one thousand five hundred dollars during each policy or contract benefit period] any other illness;

     (3) In the case of policies or contracts which provide benefits for outpatient expenses, such benefits shall be provided to the extent of [not less than fifty percent of reasonable and customary charges for twenty psychotherapy or professional counseling sessions during any policy or contract benefit period] any other illness and in accordance with section 376.811 for psychiatric services for a recognized mental illness rendered by a licensed physician specializing in the treatment of mental illness. Such benefits shall also apply to such services when rendered by a licensed psychologist, licensed professional counselor or licensed clinical social worker, unless specifically rejected by the group or individual policyholder or contract holder. [The frequency of such psychotherapy sessions may be limited, but benefits shall be available for at least one session during any seven consecutive days.]

     3. After August 28, 1997, every insurance company, health services corporation and health maintenance organization doing business in Missouri shall provide medical coverage for serious mental illness under the terms and conditions as such coverage is provided for other illnesses and diseases. Insurance coverage offered pursuant to this statute must include the same durational limits, amount limits, deductibles and coinsurance factors for serious mental illness as for other illnesses and diseases.

     4. Upon request of the reimbursing health insurers, all providers of treatment of serious mental illness shall furnish medical records or other necessary data which substantiates that initial or continued treatment is at all times medically necessary and appropriate. When the provider cannot so establish the medical necessity and/or appropriateness of the treatment modality being provided, neither the health insurer nor the patient shall be obligated to reimburse for that period or type of care which was not so established. The exception to the preceding can only be made if the patient has been informed of the above and has agreed in writing to continue to receive treatment at his or her own expense. The health insurers, when making the above determination of medically necessary and appropriate treatment, must do so in a manner consistent with that used to make the determination for the treatment of other diseases or injuries covered under the health insurance policy or agreement.

     376.811. 1. Every insurance company and health services corporation doing business in this state shall offer in all health insurance policies, benefits or coverage for chemical dependency meeting the following minimum standards:

     (1) Coverage for outpatient treatment through a nonresidential treatment program, or through partial- or full-day program services, of not less than twenty-six days per policy benefit period;

     (2) Coverage for residential treatment program of not less than twenty-one days per policy benefit period;

     (3) Coverage for medical or social setting detoxification of not less than six days per policy benefit period;

     (4) The coverages set forth in this subsection may be subject to a separate lifetime frequency cap of not less than ten episodes of treatment, except that such separate lifetime frequency cap shall not apply to medical detoxification in a life-threatening situation as determined by the treating physician and subsequently documented within forty-eight hours of treatment to the reasonable satisfaction of the insurance company or health services corporation; and

     (5) The coverages set forth in this subsection shall be:

     (a) Subject to the same coinsurance, copayment and deductible factors as apply to physical illness;

     (b) Administered pursuant to a managed care program established by the insurance company or health services corporation; and

     (c) Covered services may be delivered through a system of contractual arrangements with one or more providers, hospitals, nonresidential or residential treatment programs, or other mental health service delivery entities certified by the department of mental health, or accredited by a nationally recognized organization, or licensed by the state of Missouri.

     2. In addition to the coverages set forth in subsection 1 of this section, every insurance company [and], health services corporation and health maintenance organization doing business in this state shall offer in [all health insurance policies,] each medical expense policy or contract benefits or coverages for recognized mental illness, as defined in section 376.381, excluding chemical dependency, meeting the following minimum standards:

     (1) Coverage for outpatient treatment of not less than thirty one-hour sessions per [policy benefit period] year;

     (2) Coverage for treatment through partial- or full-day program services of not less than thirty days per [policy benefit period] year;

     (3) Coverage for residential treatment programs of not less than sixteen days per [policy benefit period] year;

     (4) Coverage for inpatient hospital treatment of not less than twelve days per [policy benefit period] year, except that such coverage shall be expanded [to not less than twenty-one days per policy benefit period] for life-threatening mental illness as determined by the treating [physician] professional and subsequently documented within forty-eight hours of treatment to the reasonable satisfaction of the insurance company, health maintenance organization or health services corporation; or in other situations involving serious mental illness as determined by the treating [physician] professional and approved by the insurance company, health maintenance organization or health services corporation;

     (5) [If the insurance company or health services corporation applies a separate lifetime maximum to the coverages set forth in this subsection, then such separate lifetime maximum shall be not less than one hundred thousand dollars;

     (6) The coverages set forth in this subsection] Coverage for recognized mental illnesses shall be subject to the same coinsurance, copayment and deductible factors as apply to physical illness; and

     [(7)] (6) The coverages set forth in this subsection shall be administered pursuant to a managed care program established by the insurance company or health services corporation, and covered services may be delivered through a system of contractual arrangements with one or more providers, community mental health centers, hospitals, nonresidential or residential treatment programs, or other mental health service delivery entities certified by the department of mental health, or accredited by a nationally recognized organization, or licensed by the state of Missouri.

     3. The offer required by sections 376.810 to 376.814 may be accepted or rejected by the group or individual policyholder or contract holder [and, if accepted, shall fully and completely satisfy and substitute for the required coverage under section 376.779. Nothing in sections 376.810 to 376.814 shall prohibit the insurance company and health services corporation from including all or part of the coverages set forth in sections 376.810 to 376.814 as standard coverage in their policies or contracts issued in this state].

     376.1350. For purposes of sections 376.1350 to 376.1390, the following terms mean:

     (1) "Adverse determination", a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the payment for the requested service is therefore denied, reduced or terminated;

     (2) "Ambulatory review", utilization review of health care services performed or provided in an outpatient setting;

     (3) "Case management", a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions;

     (4) "Certification", a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care and effectiveness;

     (5) "Clinical peer", a physician or other health care professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review;

     (6) "Clinical review criteria", the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the health carrier to determine the necessity and appropriateness of health care services;

     (7) "Concurrent review", utilization review conducted during a patient's hospital stay or course of treatment;

     (8) "Covered benefits" or "benefits", those health care services to which a covered person is entitled under the terms of a health benefit plan;

     (9) "Covered person", a policyholder, subscriber, covered person or other individual participating in a health benefit plan;

     (10) "Director", the director of the department of insurance;

     (11) "Discharge planning", the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility;

     (12) "Drug", any substance prescribed by a licensed health care provider acting within the scope of the provider's license and that is intended for use in the diagnosis, mitigation, treatment or prevention of disease. The term includes only those substances that are approved by the FDA for at least one indication;

     (13) "Emergency", a medical condition, the onset of which is sudden, of recent onset, or involves the exacerbation of a chronic condition, that manifests itself by symptoms of sufficient severity, which may include severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention to result in:

     (a) Placing the person's health in significant jeopardy;

     (b) Serious impairment to a bodily function;

     (c) Serious dysfunction of any bodily organ or part;

     (d) Inadequately controlled pain; or

     (e) With respect to a pregnant woman who is having contractions:

     a. That there is inadequate time to effect a safe transfer to another hospital before delivery; or

     b. That transfer to another hospital may pose a threat to the health or safety of the woman or unborn child;

     (14) "Emergency services", health care services that are provided in a licensed hospital's emergency facility by an appropriate provider to the extent that they are required to evaluate and treat an emergency medical condition until the condition is stabilized;

     (15) "FDA", the federal Food and Drug Administration;

     (16) "Facility", an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings;

     (17) "Grievance", a written complaint submitted by or on behalf of a covered person regarding the:

     (a) Availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;

     (b) Claims payment, handling or reimbursement for health care services; or

     (c) Matters pertaining to the contractual relationship between a covered person and a health carrier;

     (18) "Health benefit plan", a policy, contract, certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services;

     (19) "Health care professional", a physician or other health care practitioner licensed, accredited or certified by the state of Missouri to perform specified health services consistent with state law;

     (20) "Health care provider" or "provider", a health care professional or a facility;

     (21) "Health care services", services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease;

     (22) "Health carrier", an entity subject to the insurance laws and regulations of this state that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits or health services;

     (23) "Health indemnity plan", a health benefit plan that is not a managed care plan;

     (24) "Managed care plan", a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use, health care providers managed, owned, under contract with or employed by the health carrier;

     (25) "Participating provider", a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments or deductibles, directly or indirectly from the health carrier;

     (26) "Peer-reviewed medical literature", a published scientific study in a journal or other publication in which original manuscripts have been published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts, and that has been determined by the International Committee of Medical Journal Editors to have met the uniform requirements for manuscripts submitted to biomedical journals or is published in a journal specified by the United States Department of Health and Human Services pursuant to section 1861(t)(2)(B) of the Social Security Act, 107 Stat. 591 (1993), 42 U.S.C. 1395x(t)(2)(B), as amended, as acceptable peer-reviewed medical literature. Peer-reviewed medical literature does not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manu- facturing company or health carrier;

     (27) "Person", an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the foregoing;

     (28) "Prospective review", utilization review conducted prior to an admission or a course of treatment;

     (29) "Retrospective review", utilization review of medical necessity that is conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding or adjudication for payment;

     (30) "Second opinion", an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health service to assess the clinical necessity and appropriateness of the initial proposed health service;

     (31) "Stabilize", with respect to an emergency medical condition, that no material deterioration of the condition is likely to result or occur before an individual can be transferred;

     (32) "Standard reference compendia":

     (a) The American Hospital Formulary Service-Drug Information; or

     (b) The United States Pharmacopoeia-Drug Information;

     (33) "Utilization review", a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning or retrospective review. Utilization review shall not include elective requests for clarification of coverage;

     (34) "Utilization review organization", an entity that conducts utilization reviews, other than a health carrier performing a review for its own health plans.

     376.1353. A health carrier shall be responsible for monitoring all utilization review activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of sections 376.1350 to 376.1390 are met. The health carrier shall also ensure that appropriate personnel have operational responsibility for the conduct of the health carrier's utilization review program.

     376.1356. Whenever a health carrier contracts to have a utilization review organization or other entity perform the utilization review functions required by sections 376.1350 to 376.1390, the health carrier shall be responsible for monitoring the activities of the utilization review organization or entity with which the health carrier contracts and for ensuring that the requirements of sections 376.1350 to 376.1390 are met.

     376.1359. 1. A health carrier that conducts utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated, for covered services provided. The program document shall describe the following:

     (1) Procedures to evaluate the clinical necessity, appropriateness, efficacy or efficiency of health services;

     (2) Data sources and clinical review criteria used in decision making;

     (3) The process for conducting appeals of adverse determinations;

     (4) Mechanisms to ensure consistent application of review criteria and compatible decisions;

     (5) Data collection processes and analytical methods used in assessing utilization of health care services;

     (6) Provisions for assuring confidentiality of clinical and proprietary information;     

     (7) The organizational structure that periodically assesses utilization review activities and reports to the health carrier's governing body; and

     (8) The staff position functionally responsible for day-to-day program management.

     2. A health carrier shall file an annual report of its utilization review program activities with the director.

     376.1361. 1. A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health carrier may develop its own clinical review criteria, or it may purchase or license clinical review criteria from qualified vendors. A health carrier shall make available its clinical review criteria upon request by either the director of the department of health or the director of the department of insurance.

     2. A physician licensed and holding current registration in Missouri pursuant to chapter 334, RSMo, shall administer the utilization review program and oversee review decisions. All utilization review decisions which influence or may potentially influence the course of medical evaluation or treatment of a covered person are considered to be the practice of medicine by the physician making or overseeing such decisions and subject to the provisions of chapter 334, RSMo. A clinical peer shall evaluate the clinical appropriateness of adverse determinations.

     3. A health carrier shall issue utilization review decisions in a timely manner pursuant to the requirements of sections 376.1363, 376.1365 and 376.1367. A health carrier shall obtain all information required to make a utilization review decision, including pertinent clinical information. A health carrier shall have a process to ensure that utilization reviewers apply clinical review criteria consistently.

     4. A health carrier shall routinely assess the effectiveness and efficiency of its utilization review program.

     5. A health carrier's data systems shall be sufficient to support utilization review program activities and to generate management reports to enable the health carrier to monitor and manage health care services effectively.

     6. If a health carrier delegates any utilization review activities to a utilization review organization, the health carrier shall maintain adequate oversight, which shall include:

     (1) A written description of the utilization review organization's activities and responsibilities, including reporting requirements;

     (2) Evidence of formal approval of the utilization review organization program by the health carrier; and

     (3) A process by which the health carrier evaluates the performance of the utilization review organization.

     7. The health carrier shall coordinate the utilization review program with other medical management activities conducted by the carrier, such as quality assurance, credentialing, provider contracting, data reporting, grievance procedures, processes for accessing member satisfaction and risk management.

     8. A health carrier shall provide covered persons and participating providers with timely access to its review staff by a toll-free number. A health carrier shall maintain records of the wait times associated with utilization review decisions.

     9. When conducting utilization review, the health carrier shall collect only the information necessary to certify the admission, procedure or treatment, length of stay, frequency and duration of services.

     10. Compensation to persons providing utilization review services for a health carrier shall not contain incentives, direct or indirect, for these persons to make medically inappropriate review decisions. Compensation to any such persons may not be based, directly or indirectly, on the quantity or type of adverse determinations rendered.

     11. A health carrier shall permit covered persons or a provider on behalf of a covered person to appeal for the coverage of medically necessary pharmaceutical prescriptions and durable medical equipment as part of the health carriers' utilization review process.

     12. (1) A health benefit plan that conducts utilization review and provides coverage for drugs shall provide coverage for any drug prescribed to treat an indication so long as the drug has been approved by the FDA for at least one indication, if the drug is recognized for treatment of the covered indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature.

     (2) Coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug.

     (3) This subsection shall not be construed to require coverage for a drug when the FDA has determined its use to be contra-indicated for treatment of the current indication.

     (4) A drug use that is covered by reason of subdivision (1) of this subsection shall not be denied coverage based on a "medical necessity" requirement except for reasons that are unrelated to the legal status of the drug use.

     (5) Drugs or services furnished in a research trial, if the sponsor of the research trial furnishes the drugs or services without charge to any participant in the research trial shall not be subject to coverage under subdivision (1) of this subsection.

     376.1363. 1. A health carrier shall maintain written procedures for making utilization review decisions and for notifying covered persons and providers acting on behalf of covered persons of its decisions. For purposes of this section, "covered person" includes the representative of a covered person.

     2. For initial determinations, a health carrier shall make the determination within two working days of obtaining all necessary information regarding a proposed admission, procedure or service requiring a review determination. For purposes of this section, "necessary information" includes the results of any face-to-face clinical evaluation or second opinion that may be required:

     (1) In the case of a determination to certify an admission, procedure or service, the carrier shall notify the provider rendering the service by telephone within twenty-four hours of making the initial certification; and shall provide written or electronic confirmation of the telephone notification to the covered person and the provider within two working days of making the initial certification;

     (2) In the case of an adverse determination, the carrier shall notify the provider rendering the service by telephone within twenty-four hours of making the adverse determination; and shall provide written or electronic confirmation of the telephone notification to the covered person and the provider within one working day of making the adverse determination.

     3. For concurrent review determinations, a health carrier shall make the determination within one working day of obtaining all necessary information:

     (1) In the case of a determination to certify an extended stay or additional services, the carrier shall notify by telephone the provider rendering the service within one working day of making the certification; and shall provide written or electronic confirmation to the covered person and the provider within one working day after the telephone notification. The written notification shall include the number of extended days or next review date, the new total number of days or services approved, and the date of admission or initiation of services;

     (2) In the case of an adverse determination, the carrier shall notify by telephone the provider rendering the service within twenty-four hours of making the adverse determination; and shall provide written or electronic notification to the covered person and the provider within one working day of the telephone notification. The service shall be continued without liability to the covered person until the covered person has been notified of the determination.

     4. For retrospective review determinations, a health carrier shall make the determination within thirty working days of receiving all necessary information. The carrier shall notify in writing the covered person and provider rendering the services within five days of making the determination.

     5. A written notification of an adverse determination shall include the principal reason or reasons for the determination, the instructions for initiating an appeal or reconsideration of the determination, and the instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination. A health carrier shall provide the clinical rationale in writing for an adverse determination, including the clinical review criteria used to make that determination, to any party who received notice of the adverse determination and who requests such information.

     6. A health carrier shall have written procedures to address the failure or inability of a provider or a covered person to provide all necessary information for review. In cases where the provider or a covered person will not release necessary information, the health carrier may deny certification of an admission, procedure or service.

     376.1365. 1. In a case involving an initial determination or a concurrent review determination, a health carrier shall give the provider rendering the service an opportunity to request on behalf of the covered person a reconsideration of an adverse determination by the reviewer making the adverse determination.

     2. The reconsideration shall occur within one working day of the receipt of the request and shall be conducted between the provider rendering the service and the reviewer who made the adverse determination or a clinical peer designated by the reviewer if the reviewer who made the adverse determination cannot be available within one working day.

     3. If the reconsideration process does not resolve the difference of opinion, the adverse determination may be appealed by the covered person or the provider on behalf of the covered person. Reconsideration is not a prerequisite to a standard appeal or an expedited appeal of an adverse determination.

     376.1367. When conducting utilization review or making a benefit determination for emergency services:

     (1) A health carrier shall cover emergency services necessary to screen and stabilize a covered person and shall not require prior authorization of such services. With respect to care obtained from a noncontracting provider within the service area of a managed care plan, a health carrier shall cover emergency services necessary to screen and stabilize a covered person and shall not require prior authorization of the services;

     (2) A health carrier shall cover emergency services if the health carrier, acting through a participating provider or other authorized representative, has authorized the provision of emergency services. When such authorization is given, a health carrier shall issue a confirmation number to the covered person;

     (3) If a participating provider or other authorized representative of a health carrier authorizes emergency services, the health carrier shall not subsequently retract its authorization after the emergency services have been provided, or reduce payment for an item or service furnished in reliance on approval, unless the approval was based on a material misrepresentation about the covered person's health condition made by the provider of emergency services;

     (4) Coverage of emergency services shall be subject to applicable copayments, coinsurance and deductibles;

     (5) For immediately required post evaluation or post stabilization services, a health carrier shall provide access to an authorized utilization review representative twenty-four hours a day, seven days a week, to facilitate review. If an authorization decision is not made within thirty minutes of receiving a request, such services shall be deemed approved.

     376.1369. A health carrier shall annually provide a written certification to the director that the utilization review program of the health carrier or its designee complies with all applicable state and federal law establishing confidentiality and reporting requirements.

     376.1372. 1. In the certificate of coverage and the member handbook provided to covered persons, a health carrier shall include a clear and comprehensive description of its utilization review procedures, including the procedures for obtaining review of adverse determinations, and a statement of rights and responsibilities of covered persons with respect to those procedures.

     2. A health carrier shall include a summary of its utilization review procedures in material intended for prospective covered persons.

     3. A health carrier shall print on its membership cards a toll-free telephone number to call for utilization review decisions.

     376.1375. 1. A health carrier shall maintain a written register of all grievances received during a calendar year. A request for a first level review of an adverse determination shall be processed in compliance with section 376.1382 not considered a grievance for purposes of the grievance register. A request for a second level review of an adverse determination shall be considered a grievance for purposes of the grievance register. The form and content of the grievance register shall be established by the director. For each grievance the register shall contain, at a minimum, the following information:

     (1) A general description of the reason for the grievance;

     (2) Date received;

     (3) Date of each review or hearing;

     (4) Resolution at each level of the grievance;

     (5) Date of resolution at each level; and

     (6) Name of the covered person for whom the grievance was filed.

     2. (1) A health carrier shall retain the register compiled for a calendar year for the longer of three years or until the department has issued a final report for that calendar year.

     (2) A health carrier shall submit to the director, at least annually, a report in the format specified by the director. The report shall include for each type of health benefit plan offered by the health carrier:

     (a) The certificate of compliance required by section 376.1378;

     (b) The number of covered persons and the total number of grievances;

     (c) The number of grievances referred to the second level grievance review;

     (d) The number of grievances resolved at each level and their resolution;

     (e) The number of grievances appealed to the director of which the health carrier has been informed;

     (f) The number of grievances referred to alternative dispute resolution procedures or resulting in litigation; and

     (g) A synopsis of actions being taken to correct problems identified and the time necessary at each level to address the grievance;

     (h) Other information as required by the director.

     376.1378. 1. A copy of the grievance procedures, including all forms used to process a grievance, shall be filed with the director. Any subsequent material modifications to the documents also shall be filed. In addition, a health carrier shall file annually with the director, as part of its annual report required by section 376.1375, a certificate of compliance stating that the health carrier has established and maintains, for each of its health benefit plans, grievance procedures that fully comply with the provisions of sections 376.1350 to 376.1390. The director has authority to disapprove a filing that fails to comply with sections 376.1350 to 376.1390 or applicable rules and regulations.

     2. A description of the grievance procedure shall be set forth in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage provided to covered persons.

     3. The grievance procedure documents shall include a statement of a covered person's right to contact the director's office for assistance at any time. The statement shall include the toll-free telephone number and address of the department of insurance.

     376.1382. 1. A grievance involving an adverse determination may be submitted by a covered person, a covered person's representative or a provider acting on behalf of a covered person. A health carrier shall conduct a first level review of a grievance involving an adverse determination in accordance with sections 376.1387 and 376.1389, but such a grievance is not subject to the grievance register reporting requirements of section 376.1375.

     2. (1) A grievance concerning any matter except an adverse determination may be submitted by a covered person or a covered person's representative. A health carrier shall issue a written decision to the covered person or the covered person's representative within twenty working days after receiving a grievance. The person or persons reviewing the grievance shall not be the same person or persons who made the initial determination denying a claim or handling the matter that is the subject of the grievance. If the health carrier cannot make a decision within twenty working days due to circumstances beyond the carrier's control, the health carrier may take up to an additional ten working days to issue a written decision, if the health carrier provides written notice to the covered person of the extension and the reasons for the delay on or before the twentieth working day after receiving a grievance.

     (2) A covered person does not have the right to attend, or to have a representative in attendance, at the first level grievance review, but is entitled to submit written material. The health carrier shall provide the covered person the name, address and toll-free telephone number of a person designated to coordinate the grievance review on behalf of the health carrier. The health carrier shall make these rights and this information known to the covered person within three working days of receiving a grievance.

     3. Except as specified in section 376.1389, a health carrier shall use written procedures for receiving and resolving grievances from covered persons, including:

     (1) The titles and qualifying credentials of a person or persons participating in the first level grievance review process;

     (2) A statement of the reviewers' understanding of the covered person's grievance;

     (3) The reviewers' decision in clear terms and the contract basis or medical rationale in sufficient detail for the covered person to respond further to the health carrier's position;

     (4) A reference to the evidence or documentation used as the basis for the decision;

     (5) In cases involving an adverse determination, the instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination;

     (6) If applicable, a statement containing:

     (a) A description of the process to obtain a second level grievance review of a decision; and

     (b) The written procedures governing a second level review, including any required time frame for review.

     376.1385. 1. A health carrier that offers managed care plans shall establish a second level grievance review process for its managed care plans to give those covered persons who are dissatisfied with the first level grievance review decision the option to request a second level review. A covered person has the right to appear in person before authorized representatives of the health carrier at the second level grievance review process. A health carrier required by this section to establish a second level grievance review process shall provide covered persons with adequate notice of that option. A grievance concerning an adverse determination that has already received a standard review pursuant to section 376.1387 shall automatically be reviewed as a second level grievance of a managed care plan. This section shall not apply to health indemnity plans.

     2. (1) With respect to a second level review of a grievance concerning an adverse determination, a health carrier shall appoint a second level grievance review panel for each grievance. A majority of the panel shall be comprised of persons who were not previously involved in the grievance. However, a person who was previously involved with the grievance may be a member of the panel or appear before the panel to present information or answer questions. The panel's decisions are binding on the health carrier.

     (2) A health carrier shall ensure that a majority of the persons reviewing a second level grievance involving an adverse determination are health care professionals who have appropriate clinical expertise. A health carrier shall issue a copy of the written decision to a provider who submits a grievance on behalf of a covered person. In cases where there has been a denial of service, the reviewing health care professional shall not have a financial interest in the outcome of the review.

     (3) With respect to a second level review of all grievances except a grievance concerning an adverse determination, a health carrier shall appoint a second level grievance review panel for each grievance. A majority of the panel shall be comprised of employees or representatives of the health carrier who were not previously involved in the grievance. However, an employee or representative of the health carrier who was previously involved with the grievance may be a member of the panel or appear before the panel to present information or answer questions. The panel's decisions are binding on the health carrier.

     3. (1) The review panel shall schedule and hold a review meeting within twenty working days of receiving a request from a covered person for a second level review. The review meeting shall be held during regular business hours at a location reasonably accessible to the covered person. In cases where a face-to-face meeting is not practical, a health carrier shall offer the covered person the opportunity to communicate with the review panel, at the health carrier's expense, by conference call, video conferencing, or other appropriate technology. The covered person shall be notified in writing at least ten working days in advance of the review date. The health carrier shall not unreasonably deny a request for postponement of the review made by a covered person.

     (2) Upon the request of a covered person, a health carrier shall provide to the covered person all relevant information that is not confidential or privileged.

     (3) A covered person has the right to:

     (a) Attend the second level review;

     (b) Present his or her case to the review panel;

     (c) Submit supporting material both before and at the review meeting;

     (d) Ask questions of any representative of the health carrier in attendance at the review meeting; and

     (e) Be assisted or represented by a person of his or her choice.

     (4) The notice shall advise the covered person of the rights specified in subdivision (3) of this subsection.

     (5) If the health carrier desires to have an attorney present to represent the interests of the health carrier, it shall notify the covered person at least ten working days in advance of the review that an attorney will be present and that the covered person may wish to obtain legal representation of his or her own.

     (6) The covered person's right to a fair review shall not be made conditional on the covered person's appearance at the review.

     (7) The review panel shall issue a written decision to the covered person within five working days of completing the review meeting. The decision shall include:

     (a) The titles of the members of the review panel;

     (b) A statement of the review panel's understanding of the nature of the grievance and all pertinent facts;

     (c) The rationale for the review panel's decision;

     (d) Reference to evidence or documentation considered by the review panel in making that decision;

     (e) In cases involving an adverse determination, the instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination; and

     (f) Notice of the covered person's right to file an appeal with the director's office of the second level review panel's decision. The notice shall contain the toll-free telephone number and address of the director's office. The director shall resolve any such grievance through any means with the director's sole discretion and not specifically prohibited by law, including, but not limited to, referral of such grievance to a panel of health care professionals who are appointed by the director and who have appropriate expertise. The grievance and resolution of such grievance shall not be considered a contested case within the meaning of section 536.010, RSMo, but the resolution of such grievance by the director shall be considered a final agency decision within the director's discretion, binding upon the covered person and health carrier, and subject to judicial review accordingly under sections 536.100 to 536.140, RSMo. In any action for such judicial review, the covered person and the health carrier shall be deemed real parties in interest.

     376.1387. A health carrier shall establish both a standard and an expedited appeals process. For a standard appeal, the provider shall:

     (1) Establish written procedures for a standard appeal of an adverse determination. Appeal procedures shall be available to the covered person, the representative of a covered person and to the provider acting on behalf of the covered person;

     (2) Ensure that appeals are evaluated by an appropriate clinical peer or peers in the same or similar specialty as would typically manage the case being reviewed. The clinical peer shall not have been involved in the initial adverse determination;

     (3) Notify in writing both the covered person and the attending or ordering provider of the decision within fifteen working days following the request for an appeal. The written decision shall contain:

     (a) The titles and qualifying credentials of the person or persons evaluating the appeal;

     (b) A statement of the reviewers' understanding of the reason for the covered person's request for an appeal;

     (c) The reviewers' decision in clear terms and the medical rationale in sufficient detail for the covered person to respond further to the health carrier's position;

     (d) A reference to the evidence or documentation used as the basis for the decision, including the clinical review criteria used to make the determination, and instructions for requesting the clinical review criteria; and

     (e) A description of the process for submitting a grievance in writing requesting a further review of the case;

     (4) Ensure that in any case where the standard review process does not resolve a difference of opinion between the health carrier and the covered person or the provider acting on behalf of the covered person, the covered person or the provider acting on behalf of the covered person may submit a written grievance, unless the provider is prohibited from filing a grievance by federal or other state law. A health carrier that offers managed care plans shall review a written grievance of an adverse determination as a second level grievance.

     376.1389. 1. A health carrier shall establish written procedures for the expedited review of a grievance involving a situation where the timeframe of the standard grievance procedures set forth in sections 376.1382, 376.1385 and 376.1387 would seriously jeopardize the life or health of a covered person or would jeopardize the covered person's ability to regain maximum function. A request for an expedited review may be submitted orally or in writing. A request for an expedited review of an adverse determination may be submitted orally and shall be subject to the review procedures of this section if it meets the criteria of this section. However, for purposes of the grievance register requirements in section 376.1375, the request shall be considered an appeal of a utilization review adverse determination and not a grievance unless the request is submitted in writing. Expedited review procedures shall be available to a covered person and to the provider acting on behalf of a covered person. For purposes of this section, covered person includes the representative of a covered person.

     2. Expedited reviews shall be evaluated by an appropriate clinical peer or peers in the same or similar specialty as would typically manage the case being reviewed. The clinical peer or peers shall not have been involved in the initial adverse determination.

     3. A health carrier shall provide expedited review to all requests concerning an admission, availability of care, continued stay or health care service for a covered person who has received emergency services but has not been discharged from a facility.

     4. An expedited review may be initiated by a covered person or a provider acting on behalf of a covered person.

     5. In an expedited review, all necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or the provider acting on behalf of the covered person by telephone, facsimile or the most expeditious method available.

     6. In an expedited review, a health carrier shall make a decision and notify the covered person as expeditiously as the covered person's medical condition requires, but in no event more than seventy-two hours after the review is commenced. If the expedited review is a concurrent review determination, the service shall be continued without liability to the covered person until the covered person has been notified of the determination.

     7. A health carrier shall provide written confirmation of its decision concerning an expedited review within two working days of providing notification of that decision, if the initial notification was not in writing. The written decision shall contain the provisions required in subsection 3 of section 376.1382.

     8. A health carrier shall provide reasonable access, not to exceed one business day after receiving a request for an expedited review, to a clinical peer who can perform the expedited review.

     9. In any case where the expedited review process does not resolve a difference of opinion between the health carrier and the covered person or the provider acting on behalf of the covered person, the covered person or the provider acting on behalf of the covered person may submit a written grievance, unless the provider is prohibited from filing a grievance by federal or other state law. A health carrier that offers managed care plans shall review it as a second level grievance. In conducting the review, the health carrier shall adhere to time frames that are reasonable under the circumstances.

     10. A health carrier shall not provide an expedited review for retrospective adverse determinations.

     376.1390. The director shall carry out the provisions of sections 376.1350 to 376.1390.