Current through Register Vol. 49, No. 2, February 2024
Section
1. Authority
This regulation is issued under the authority of Ark. Code Ann.
§§
23-61-108,
23-63-1806,
25-15-201,
etseq., and any other applicable laws.
Section 2. Definitions
a. "Covered person" means a person on whose
behalf a health care insurer offering health insurance coverage is obligated to
pay benefits or provide services.
b. "Health care insurer" means an entity
subject to the insurance laws of this state or the jurisdiction of the
Insurance Commissioner that contracts or offers to contract to provide health
insurance coverage, including, but not limited to, an insurance company, a
health maintenance organization, or a hospital medical service
corporation.
c. "Health care
provider" means any person or entity providing:
(1) Medical, pharmacy, optometric, or dental
care;
(2) Hospitalization;
or
(3) Any other services and goods
used for the purpose or incidental to the purpose of preventing, alleviating,
curing, or healing human illness or injury.
d.
(1)
"Health insurance coverage" means benefits consisting of medical, pharmacy,
optometric, or dental care, hospitalization, or other goods or services for the
purpose of preventing, alleviating, curing, or healing human illness provided,
directly or indirectly, through insurance, reimbursement, or otherwise,
including items and services paid for under any policy, certificate, or
agreement offered by a health care insurer.
(2) "Health insurance coverage" does not
include policies or certificates covering only accident, credit, disability
income, long-term care, hospital indemnity, Medicare supplemental policy as
defined in
42
U.S.C. §
1395ss(g)(1), a
specified disease, other limited benefit health insurance, automobile medical
payment insurance, or claims under the Workers' Compensation Law, §
11-9-101
et seq., Public Employees Workers' Compensation Act, §
21-5-601
et seq., or the Arkansas Comprehensive Health Insurance Pool
Act, §
23-79-501
et seq.
e. "Recoupment" means any action or attempt
by a health care insurer to recover or collect payments already made to a
health care provider with respect to a claim:
(1) By reducing other payments currently owed
to the health care provider;
(2) By
withholding or setting off the amount against current or future payments to the
health care provider;
(3) By
demanding payment back from a health care provider for a claim already paid;
or
(4) In any other manner that
reduces or affects the future claim payments to the health care
provider.
Section
3. Time
a. Except in cases of
fraud committed by the health care provider, a health care insurer may only
exercise recoupment from a provider during the eighteen-month period after the
date that the health care insurer paid the claim submitted by the health care
provider.
b.
(1) A health care insurer that exercises
recoupment under this section shall give the health care provider a written or
electronic statement specifying the basis for the recoupment.
(2) The statement shall contain, at a
minimum, the information required by Section 5.
Section 4. Persons Not Covered
a. If a health care insurer determines that
payment was made for services not covered under the covered person's health
insurance coverage, the health care insurer shall give written notice to the
health care provider of its intent to exercise recoupment and may:
(1) Request a refund from the health care
provider; or
(2) Make a recoupment
of the payment from the health care provider in accordance with Section 5.
b.
(1) Except in the case of fraud committed by
the health care provider or as provided in subdivision b.(2) of this section,
subsection a. of this section shall not apply if a health care provider or
other party on its behalf verified from the health care insurer or its agent
that an individual was a covered person and if the health care provider in good
faith provided services to the individual in reliance on the
verification.
(2) A health care
insurer has one hundred twenty (120) days from the date of payment to notify
the provider of a verification error and the fact that services rendered will
not be covered if the error was made in good faith at the time of the
verification.
Section
5. Required Disclosures
If a health care insurer exercises recoupment, then the health
care insurer shall provide the health care provider written documentation that
specifies the:
(1) Amount of the
recoupment;
(2) Covered person's
name to which the recoupment applies;
(3) Patient identification number;
(4) Date or dates of service;
(5) Service or services on which the
recoupment is based;
(6) Pending
claims being recouped or future claims that will be recouped; and
(7) Specific reason for the
recoupment.
Section 6.
Violations
The failure to comply with any provision of this subchapter shall
be deemed an unfair trade practice under the Trade Practices Act, §
23-66-201
etseq.
and may be punished by the fines and penalties established under §§
23-66-210,
23-60-108, and
23-66-215.
Section 7. Effective Date
This Rule shall be effective January 1, 2006. The Rule shall
apply to all payments made by health care insurers to providers on or after
August 12, 2005, the effective date of Act 422 of 2005.
(signed by Julie Benafield Bowman)
JULIE BENAFIELD BOWMAN
INSURANCE COMMISSIONER
December 16, 2005
DATE
