20 CSR 400-10.200 - Authorization For Health Care Services Not To Be Withdrawn After the Services Have Been Provided, Exceptions
PURPOSES: This rule interprets sections 376.1350(4), 376.1359, 376.1361.12 and 376.1361.13, RSMo Supp. 1997.
(1) Utilization review by health carriers for
plans containing a managed care component is performed only for covered
services, section
376.1359,
RSMo Supp. 1997. Therefore, a benefits determination must be performed prior to
utilization review under sections
376.1350(4),
376.1361.12
and 376.1361.13, RSMo Supp. 1997. Because a benefits determination must be made
prior to utilization review, certification will be deemed to be an
authorization of a covered benefit. If an authorized representative of a health
carrier authorizes the provision of a health care service, the health carrier
shall not subsequently retract its authorization after the health care service
has been provided, or reduce payment for an item or service furnished in
reliance on approval, unless-
(A) Such
authorization is based on a material misrepresentation or omission about the
treated person's health condition or the cause of the health condition;
or
(B) The health benefit plan
terminates before the health care services are provided; or
(C) The covered person's coverage under the
health benefit plan terminates before the health care services are
provided.
(2) Where a
health carrier has authorized the provision of a health care service and a
dispute arises between the health carrier and the provider after the service is
rendered concerning whether the provider provided the service in a manner or
type authorized by the health carrier, the health carrier must hold the
enrollee harmless from claims made against the enrollee by the provider
concerning the service, except for applicable copayments, coinsurance and
deductibles. Failure to hold the enrollee harmless will be deemed a violation
of section 376.1361.13, RSMo as an indirect retraction of the authorization.
Notwithstanding any provision of this rule, sections 376.1350-376.1390, RSMo
Supp. 1997, do not determine or allocate the responsibility for utilization
review decisions as between the health carrier and providers.
Notes
*Original authority: 374.045, RSMo 1967, amended 1993, 1995.
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