3 AAC 26.110 - Additional standards for prompt, fair, and equitable settlements of health claims
(a) A person who
provides coverage in this state for health care services or supplies on an
expense incurred basis for which benefits are based on an amount that is less
than the actual amount billed for the health care services or supplies shall
(1) for a vaccine covered by an insurance
policy that is an included vaccine and purchased by a provider instead of
obtained from the state under the statewide immunization program established
under AS
18.09.200, determine the final payment for
the covered vaccine at an amount equal to or greater than the cost of the
state-purchased vaccine under the statewide immunization program; in this
paragraph, "included vaccine" has the meaning given in
AS
18.09.990;
(2) provide an explanation of the basis of
payments in clear and simple terms with any claim payment and document the
provided explanation in the claim file; and
(3) provide an explanation of the basis of
payments in the health insurance policy, including any payments for which a
covered individual may be responsible, and include on any schedule or summary
of benefits page accompanying the policy a statement regarding whether the
covered individual is responsible for any amount billed for a health care
service or supply item that exceeds the final payment.
(b) This section does not apply to workers'
compensation claims.
(c) If a
person who is required to include a coordination of benefits provision under
AS
21.42.205 provides coverage on a secondary
basis,
(1) absent evidence of fraud, the
secondary insurer must accept the primary insurer's precertification,
utilization review, or other managed care requirement determination and may not
deny, delay, or reduce benefits under its policy for a covered person who has
met the primary insurer's precertification, utilization review, or other
managed care requirement; and
(2)
the secondary insurer must calculate its covered benefits at no greater cost to
the covered person than if the health care services were obtained from the
secondary insurer's participating provider if
(A) the secondary policy provides benefits
through a provider network but the primary insurer's policy does not provide
coverage through a provider network;
(B) both the primary policy and the secondary
policy provide benefits through provider networks but the covered person
obtains health care services from a provider that is in the provider network of
the primary insurer but not the provider network of the secondary insurer;
or
(C) both the primary policy and
the secondary policy provide benefits through provider networks but the covered
person obtains health care services from a provider that is not part of the
provider network of the primary insurer or the secondary insurer because no
provider in the primary insurer's provider network is able to meet the
particular health need of the covered person.
(d) A health care insurer shall give written
notice to a health care provider, health care facility, or consumer at least 30
calendar days before the insurer seeks recovery of an overpayment. The notice
must include adequate information for the health care provider, health care
facility, or consumer to identify the specific claim and the specific reason
for the recovery. A health care insurer may not initiate recovery of an
overpayment more than 365 days after the date the original payment was made to
a health care provider, health care facility, or consumer, or its agents,
unless the health care insurer has clear and documented reason to believe that
the health care provider, the health care facility, or consumer, or its agents
has committed fraud or other intentional misconduct.
(e) A health care insurer shall provide a
health care provider, health care facility, or consumer with an opportunity to
challenge the recovery of an overpayment, including sharing of claims
information, and shall establish written policies and procedures for a health
care provider, health care facility, or consumer to follow in order to
challenge the recovery of an overpayment.
(f) If a health insurance policy provides
in-network and out-of-network benefits, the policy must provide at a minimum
the in-network benefit level for the following:
(1) emergency services;
(2) services or supplies provided by an
out-of-network health care provider or health care facility, if an in-network
health care provider or health care facility is not reasonably accessible as
defined in the policy;
(3) services
provided by an out-of-network health care provider as part of a covered stay at
an in-network health care facility when a covered individual does not have or
is not given a choice of health care provider.
(g) An insurer may require a covered
individual to purchase specialty drugs from a specific in-network health care
provider in order to receive benefits under a health insurance policy, unless
the specialty drug is not available from the health care provider when needed
and a delay in receiving the drug would threaten the efficacy of treatment or
the life of the covered individual.
(h) An insurer may require a covered
individual to receive transplant services from an in network health care
provider in order to receive benefits under a health insurance policy, unless
transplant services are not available from a network health care provider when
needed and a delay in receiving the transplant services would threaten the
efficacy of treatment or the life of the covered individual.
(i) An insurer may not process claims based
on a procedure code that differs from the procedure code specified in the claim
unless agreed upon by the health care provider that provided the service or
supply.
(j) If an insurer provides
benefits to a domestic partner, then the insurer may not unfairly discriminate
on the basis of gender and must provide benefits to both same and opposite
gender domestic partners.
(k) If an
insurer, for purposes of negotiating discounts with a health care provider,
delays payment of an otherwise clean claim beyond the timeframes under
AS
21.36.495, the insurer is subject to the 15
percent interest penalty under
AS
21.36.495(c) or
(d).
(l) An insurer may not reduce the payment on
a current claim for an overpayment on a previous claim unless the reduction
(1) is determined to be in compliance with
(d) and (e) of this section; and
(2) does not result in a reduction on the
amount allowed on any other claims of the covered
individual.
Notes
In 2010 the revisor of statutes, acting under AS 01.05.031, redesignated former AS 21.36.350 as AS 21.36.125(c). As of Register 196 (January 2011), the regulations attorney made a conforming technical revision under AS 44.62.125(b)(6), to the authority citation that follows 3 AAC 26.110, deleting the citation to former AS 21.36.350 to reflect that the authority citation already includes a citation to AS 21.36.125, the section where material formerly in AS 21.36.350 was relocated.
Authority:AS 21.06.090
AS 21.36.125
AS 21.36.495
AS 21.42.205
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