354.606. Providers notified of specific covered services, when--hold harmless provision--cessation of operations procedure--selection standards for health care professionals, filing with the departmen

MISSOURI STATUTES AND CODES

354.606. Providers notified of specific covered services, when--hold harmless provision--cessation of operations procedure--selection standards for health care professionals, filing with the departmen

Providers notified of specific covered services, when--hold harmlessprovision--cessation of operations procedure--selection standards forhealth care professionals, filing with the department.

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

2. Every contract between a health carrier and a participatingprovider shall set forth a hold harmless provision specifying protectionfor enrollees. This requirement shall be met by including a provisionsubstantially similar to the following:

"Provider agrees that in no event, including but not limited tononpayment by the health carrier or intermediary, insolvency of the healthcarrier or intermediary, or breach of this agreement, shall the providerbill, charge, collect a deposit from, seek compensation, remuneration orreimbursement from, or have any recourse against an enrollee or a person,other than the health carrier or intermediary, acting on behalf of theenrollee for services provided pursuant to this agreement. This agreementshall not prohibit the provider from collecting coinsurance, deductibles orco-payments, as specifically provided in the evidence of coverage, or feesfor uncovered services delivered on a fee-for-service basis to enrollees.This agreement shall not prohibit a provider, except for a health careprofessional who is employed full time on the staff of a health carrier andhas agreed to provide service exclusively to that health carrier'senrollees and no others, and an enrollee from agreeing to continue servicessolely at the expense of the enrollee, as long as the provider has clearlyinformed the enrollee that the health carrier may not cover or continue tocover a specific service or services. Except as provided herein, thisagreement does not prohibit the provider from pursuing any available legalremedy; including, but not limited to, collecting from any insurancecarrier providing coverage to a covered person."

3. Every contract between a health carrier and a participatingprovider shall set forth that in the event of a health carrier's orintermediary's insolvency or other cessation of operations, coveredservices to enrollees shall continue through the period for which a premiumhas been paid to the health carrier on behalf of the enrollee or until theenrollee's discharge from an inpatient facility, whichever time is greater.

4. The contract provisions satisfying the requirements of subsections2 and 3 of this section shall:

(1) Be construed in favor of the enrollee;

(2) Survive the termination of the contract regardless of the reasonfor termination, including the insolvency of the health carrier; and

(3) Supersede any oral or written contrary agreement between aprovider and an enrollee or the representative of an enrollee if thecontrary agreement is inconsistent with the hold harmless and continuationof covered services provisions required by subsections 2 and 3 of thissection.

5. In no event shall a participating provider collect or attempt tocollect from an enrollee any money owed to the provider by the healthcarrier nor shall a participating provider collect or attempt to collectfrom an enrollee any money in excess of the coinsurance, co-payments ordeductibles. Failure of a health carrier to make timely payment of anamount owed to a provider in accordance with the provider's contract shallconstitute an unfair claims settlement practice subject to sections375.1000 to 375.1018, RSMo.

6. (1) A health carrier shall develop selection standards forparticipating primary care professionals and each participating health careprofessional specialty. Such standards shall be in writing and used indetermining the selection of health care professionals by the healthcarrier, its intermediaries and any provider networks with which itcontracts. Selection criteria shall not be established in a manner thatwill:

(a) Allow a health carrier to avoid a high-risk population byexcluding a provider because such provider is located in a geographic areathat contains a population presenting a risk of higher than average claims,losses or health services utilization; or

(b) Exclude a provider because such provider treats or specializes intreating a population presenting a risk of higher than average claims,losses or health services utilization.

(2) Paragraphs (a) and (b) of subdivision (1) of this subsectionshall not be construed to prohibit a health carrier from declining toselect a provider who fails to meet the other legitimate selection criteriaof the health carrier developed in compliance with sections 354.600 to354.636.

(3) The provisions of sections 354.600 to 354.636 shall not require ahealth carrier, its intermediaries or the provider networks with which itcontracts, to employ specific providers or types of providers, or tocontract with or retain more providers or types of providers than arenecessary to maintain an adequate network.

7. A health carrier shall file its selection standards forparticipating providers with the director. A health carrier shall alsofile any subsequent changes to its selection standards with the director.The selection standards shall be made available to licensed health careproviders.

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

9. No contract between a health carrier and a provider for thedelivery of health care service, entered into or renewed after August 28,2001, shall require the mandatory use of a hospitalist. For purposes ofthis subsection, "hospitalist" means a physician who becomes a physician ofrecord at a hospital for a patient of a participating provider and who mayreturn the care of the patient to that participating provider at the end ofhospitalization.

10. A health carrier shall not offer an inducement under the managedcare plan to a provider to provide less than medically necessary servicesto an enrollee.

11. A health carrier shall not prohibit a participating provider fromadvocating in good faith on behalf of enrollees within the utilizationreview or grievance processes established by the health carrier or a personcontracting with the health carrier.

12. A health carrier shall require a provider to make health recordsavailable to appropriate state and federal authorities involved inassessing the quality of care but shall not disclose individual identities,or investigating the grievances or complaints of enrollees, and to complywith the applicable state and federal laws related to the confidentialityof medical or health records.

13. The rights and responsibilities of a provider under a contractbetween a health carrier and a participating provider shall not be assignedor delegated by the provider without the prior written consent of thehealth carrier.

14. A health carrier shall be responsible for ensuring that aparticipating provider furnishes covered benefits to all enrollees withoutregard to the enrollee's enrollment in the plan as a private purchaser ofthe plan or as a participant in a publicly financed program of health careservice.

15. A health carrier shall notify the participating providers oftheir obligations, if any, to collect applicable coinsurance, co-paymentsor deductibles from enrollees pursuant to the evidence of coverage, or ofthe providers' obligations, if any, to notify enrollees of their personalfinancial obligations for noncovered services.

16. A health carrier shall not penalize a provider because theprovider, in good faith, reports to state or federal authorities any act orpractice by the health carrier that may jeopardize patient health orwelfare.

17. A health carrier shall establish a mechanism by which aparticipating provider may determine in a timely manner whether a person iscovered by the carrier.

18. A health carrier shall not discriminate between health careprofessionals when selecting such professionals for enrollment in thenetwork or when referring enrollees for health care services to be providedby such health care professional who is acting within the scope of hisprofessional license.

19. A health carrier shall establish procedures for resolution ofadministrative, payment or other disputes between providers and the healthcarrier.

20. A contract between a health carrier and a provider shall notcontain definitions or other provisions that conflict with the definitionsor provisions contained in the managed care plan or sections 354.600 to354.636.