26.1-47 Preferred Provider Organizations - North Dakota Statutes

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CHAPTER 26.1-47PREFERRED PROVIDER ORGANIZATIONS26.1-47-01. Definitions. As used in this chapter, unless the context indicates otherwise:1."Commissioner" means the insurance commissioner of the state of North Dakota.2."Covered person" means any person on whose behalf the health care insurer is
obligated to pay for or provide health care services.3."Health benefit plan" means the health insurance policy or subscriber agreement
between the covered person or the policyholder and the health care insurer which
defines the services covered.4."Health care insurer" includes an insurance company as defined in section
26.1-02-01, a health service corporation as defined in section 26.1-17-01, a health
maintenance organization as defined in section 26.1-18.1-01, and a fraternal benefit
society as defined in section 26.1-15.1-02.5."Health care provider" means licensed providers of health care services in this state.6."Health care services" means services rendered or products sold by a health care
provider within the scope of the provider's license.The term includes hospital,medical, surgical, dental, vision, chiropractic, and pharmaceutical services or
products.7."Preferred provider" means a duly licensed health care provider or group of
providers who have contracted with the health care insurer, under this chapter, to
provide health care services to covered persons under a health benefit plan.8."Preferred provider arrangement" means a contract between the health care insurer
and one or more health care providers which complies with all the requirements of
this chapter.26.1-47-02. Preferred provider arrangements. Notwithstanding any provision of law tothe contrary, any health care insurer may enter into preferred provider arrangements.1.Preferred provider arrangements must:a.Establish the amount and manner of payment to the preferred provider. The
amount and manner of payment may include capitation payments for preferred
providers.b.Include mechanisms, subject to the minimum standards imposed by chapter
26.1-26.4, which are designed to review and control the utilization of health
care services and establish a procedure for determining whether health care
services rendered are medically necessary.c.Include mechanisms which are designed to preserve the quality of health care.d.With regard to an arrangement in which the preferred provider is placed at risk
for the cost or utilization of health care services, specifically include a
description of the preferred provider's responsibilities with respect to the health
care insurer's applicable administrative policies and programs, including
utilizationreview,qualityassessmentandimprovementprograms,credentialing, grievance procedures, and data reporting requirements.Anyadministrative responsibilities or costs not specifically described or allocated inPage No. 1the contract establishing the arrangement as the responsibility of the preferred
provider are the responsibility of the health care insurer.e.Provide that in the event the health care insurer fails to pay for health care
services as set forth in the contract, the covered person is not liable to the
provider for any sums owed by the health care insurer.f.Provide that in the event of the health care insurer insolvency, services for a
covered person continue for the period for which premium payment has been
made and until the covered person's discharge from inpatient facilities.g.Provide that either party terminating the contract without cause provide the
other party at least sixty days' advance written notice of the termination.2.Preferred provider arrangements may not unfairly deny health benefits to persons for
covered medically necessary services.3.Preferred provider arrangements may not restrict a health care provider from
entering into preferred provider arrangements or other arrangements with other
health care insurers.4.A health care insurer must file all its preferred provider arrangements with the
commissioner within ten days of implementing the arrangements. If the preferred
provider arrangement does not meet the requirements of this chapter, the
commissioner may declare the contract void and disapprove the preferred provider
arrangement in accordance with the procedure for policies set out in chapter
26.1-30.5.A preferred provider arrangement may not offer an inducement to a preferred
provider to provide less than medically necessary services to a covered person.
This subsection does not prohibit a preferred provider arrangement from including
capitation payments or shared-risk arrangements authorized under subdivision a of
subsection 1 which are not tied to specific medical decisions with respect to a
patient.6.A health care insurer may 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 jeopardizes patient health or welfare.26.1-47-03. Health benefits plans.1.Health care insurers may issue policies or subscriber agreements which provide for
incentives for covered persons to use the health care services of preferred providers.
These policies or subscriber agreements must contain all of the following provisions:a.A provision that if a covered person receives emergency care and cannot
reasonably reach a preferred provider that care will be reimbursed as though
the covered person had been treated by a preferred provider.b.A provision that if covered services are not available through a preferred
provider, reimbursement for those services will be made as though the covered
person had been treated by a preferred provider.c.A provision which clearly discloses differentials between benefit levels for
health care services of preferred providers and benefit levels for health care
services of other providers.d.A provision that entitles the covered person, if any health care services covered
under the health benefit plan are not available through a preferred providerPage No. 2within fifty miles [80.47 kilometers] of the policyholder's legal residence, to the
provision of those covered services under the health benefit plan by a health
care provider not under contract with the health care insurer and located within
fifty miles [80.47 kilometers] of the policyholder's legal residence.For thecovered person to be eligible for benefits under this subdivision, the health care
provider not under contract with the health care insurer must furnish the health
care services at the same cost or less that would have been incurred had the
covered person secured the health care services through a preferred provider.2.If the policy or subscriber agreement provides differences in benefit levels payable to
preferred providers compared to other providers, the differences may not unfairly
deny payment for covered services and may be no greater than necessary to
provide a reasonable incentive for covered persons to use the preferred provider.26.1-47-04. Preferred provider participation requirements. Health care insurers mayplace reasonable limits on the number of classes of preferred providers which satisfy the
standards set forth by the health care insurer, provided that there be no discrimination against
any providers on the basis of religion, race, color, national origin, age, sex, or marital status, and
further provided that selection of preferred providers is made on the combined basis of least cost
and highest quality of service.26.1-47-05. General requirements. Health care insurers complying with this chapterare subject to all other applicable laws, rules, and regulations of this state.26.1-47-06.Rules.The commissioner may adopt rules necessary to enforce andadminister this chapter.26.1-47-07.Penalty.The commissioner may levy an administrative penalty not toexceed ten thousand dollars for a violation of this chapter. Any person who violates this chapter
is guilty of a class A misdemeanor.Page No. 3Document Outlinechapter 26.1-47 preferred provider organizations