02-031 C.M.R. ch. 790, § 4 - Interim Dispute Resolution

A. The interim dispute resolution requirements of this Rule apply to the following types of health plans:

(1) All health insurance policies; nonprofit hospital, medical, or health service contracts; and similar health coverage contracts, whether offered on a group basis or on an individual, family, blanket, or "nongroup" basis;

(2) Coverage through health maintenance organizations;

(3) The medical payments coverage in automobile insurance policies; and

(4) Self-insured plans subject to state regulation as described in 24-A M.R.S.A, §2848-A.

B. Interim Payment. If the carriers cannot agree on the order of benefits within thirty (30) calendar days after the carriers have received all of the information needed to pay the claim and determine the order of benefits, the carriers shall immediately pay the claim in equal shares and determine their relative liabilities following payment, except that no carrier shall be required to pay more than it would have paid had it been primary.

C. Noncomplying Plans. If the primary plan is not subject to the jurisdiction of the Superintendent and the primary carrier refuses to pay the full amount for which it is responsible, the secondary carrier shall pay the remainder on a provisional basis, up to the additional amount for which it would be responsible if its plan were primary, without prejudice to any right it might have to recover that amount from the primary carrier in another forum. The carrier issuing the complying plan shall be subrogated to the rights of the employee, subscriber, or member under the noncomplying plan on a just and equitable basis, consistent with 24-AM.R.S.A. §§2729-A, 2836 and 4243. The same procedure shall apply if the Superintendent has jurisdiction over the primary plan but is compelled by applicable choice-of-law principles to permit the primary plan to pay as a secondary plan. As a condition of its provisional payment obligation under this Subsection, the carrier may require the employee, subscriber, or member to provide written approval of the carrier's subrogation right.

Notes

02-031 C.M.R. ch. 790, § 4