§ 108A-55.4. Insurers to provide certain information to Department of Health and Human Services. - North Carolina Statutes

§ 108A‑55.4.  Insurersto provide certain information to Department of Health and Human Services.

(a)        As used in thissection, the terms:

(1)        "Applicant"means an applicant or former applicant of medical assistance benefits.

(1a)      "Department"means the Department of Health and Human Services.

(2)        "Division"means the Division of Medical Assistance of the Department of Health and HumanServices.

(3)        "Healthinsurer" includes self‑insured plans, group health plans (as definedin section 607(1) of the Employee Retirement Income Security Act of 1974, [29USC Section 1167(1)]), service benefit plans, managed care organizations, orother parties that are, by statute, contract, or agreement, legally responsiblefor payment of a claim for a health care item or service as a condition ofdoing business in the State.

(4)        "Medicalassistance" means medical assistance benefits provided under the StateMedical Assistance Plan.

(5),       (6) Reserved forfuture codification.

(7)        "Recipient"means a present or former recipient of medical assistance benefits.

(8)        "Request"means any inquiry by the Department or Division for the purpose of determiningthe existence of insurance where the Department or Division may have expendedpublic assistance benefits.

(9)        "Subscriber"means the policyholder or covered person under the insurance policy.

(b)        Health insurers,and pharmacy benefit managers regulated as third‑party administratorsunder Article 56 of Chapter 58 of the General Statutes, shall provide, withrespect to a subscriber upon request of the Division or its authorizedcontractor, information to determine during what period the individual or theindividual's spouse or dependents may be (or may have been) covered by a healthinsurer and the nature of the coverage that is or was provided by the healthinsurer (including the subscriber's name, address, identification number,social security number, date of birth and identifying number of the plan) in amanner prescribed by the Division or its authorized contractor. Notwithstandingany other provision of law, every health insurer shall provide, not morefrequently than twelve times in a year and at no cost, to the Department ofHealth and Human Services, Division of Medical Assistance, or the Department'sor Division's authorized contractor, upon its request, information as necessaryso that the Division may (i) identify applicants or recipients who may also besubscribers covered under the benefit plans of the health insurer; (ii)determine the period during which the individual, the individual's spouse, orthe individual's dependents may be or may have been covered by the healthbenefit plan; and (iii) determine the nature of the coverage. To facilitate theDivision or its authorized contractor in obtaining this and other related information,every health insurer shall:

(1)        Cooperate with theDivision to determine whether a named individual who is a recipient of medicalassistance may be covered under the insurer's health benefit plan and eligibleto receive benefits under the health benefit plan for services provided underthe State Medical Assistance Plan.

(2)        Respond to therequest for payment within 90 working days after receipt of written proof ofloss or claim for payment for health care services provided to a recipient ofmedical assistance who is covered by the benefit plan of the health insurer.

(3)        Accept theDivision's right of recovery and the assignment to the Division of any right ofan individual or other entity to payment from the party for an item or servicefor which payment has been made under the State Medical Assistance Plan.

(4)        Respond to anyinquiry by the Division or its authorized contractor regarding a claim forpayment for any health care item or service that is submitted not later thanthree years after the date of the provision of the health care item or service.

(5)        Notwithstandingsubsection (d) of this section, agree not to deny a claim submitted by theDivision solely on the basis of the date of submission of the claim, the typeof format of the claim form, or a failure to present proper documentation atthe point‑of‑sale that is the basis of the claim, if:

a.         The claim issubmitted by the Division within the three‑year period beginning on thedate on which the item or service was furnished; and

b.         Any action by theDivision to enforce its rights with respect to such claim is commenced withinsix years of the Division's submission of the claim.

(c)        A health insurerthat complies with this section shall not be liable on that account in anycivil or criminal actions or proceedings.

(d)        A health insurer isobligated to reimburse the Department only if the insurer has a contractualobligation to make payment for the covered service or item. (2006‑66, s. 10.8; 2006‑221,ss. 9(a)‑(c); 2007‑442, s. 2.)