California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 2 - Policy Forms and Other Documents
Article 6 - Provider Network Access Standards for Health Insurance
Section 2240.4 - Contracts with Network Providers

Universal Citation: 10 CA Code of Regs 2240.4

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) Insurers shall establish written policies and procedures for recruiting network providers, credentialing network providers, contracting with network providers, and managing their networks.

(b) Effective June 30, 2008, contracts between network providers and insurers or their agents shall:

1) be in writing and be fair and reasonable as to the parties to such contracts;

2) provide that network providers shall not make any additional charges for rendering network services except as provided for in the contract between the insurer and the insured;

3) include all the agreements between the parties pertaining to the rendering of network provider services;

4) recite that the provider's primary consideration shall be the quality of the health care services rendered to covered persons;

5) include provisions ensuring that providers shall not discriminate against any insured in the provision of contracted services on the basis of sex, marital status, sexual orientation, race, color, religion, ancestry, national origin, disability, health status, health insurance coverage, utilization of medical or mental health or substance use disorder services or supplies, or other unlawful basis including without limitation, the filing by such insured of any complaint, grievance, or legal action against a provider.

(c) Insurers shall afford essential community providers equal opportunity to participate in contracts for alternative rates of payment to assure adequacy of number and location of institutional facilities and professional providers in what have been determined to be underserved communities and populations.

(1) An insurer shall not discriminate against a provider on the basis of the provider's qualifying as an essential community provider under state or federal law.

(2) When contracting with an essential community provider, an insurer shall offer contractual terms that are fair and reasonable, and similar to the terms offered to other similarly situated providers.

(3) Nothing in this section shall be construed to require an insurer to contract with an essential community provider if such provider refuses to accept the generally applicable payment rates of the insurer.

(d) An insurer shall notify the Department at least 10 days before the termination of a contract with a provider, provider group, or facility, and in such notice shall demonstrate that its network remains in compliance with the network adequacy requirements of this Article. The notice shall be electronically filed with the Health Policy Approval Bureau through the "California Life & Health" instance of the System for Electronic Rate and Form Filing (SERFF) of the National Association of Insurance Commissioners (NAIC), with the title "2240.4(d) Provider/Facility Termination Notice" in the subject line. In demonstrating compliance, the notice shall describe the other providers or facilities that enable the network to continue to comply with the requirements of this article, notwithstanding the termination of the identified provider(s) or facility/facilities. For providers, an updated report as described in Section 2240.5(c)(1) is an adequate description. For facilities, the other facilities shall be identified, within an updated report as described in Section 2240.5(c)(1).

(e) If a provider has contracted with an insurer to participate in a particular network, the insurer must obtain the provider's written assent before that provider may be included as a participant in other networks of that insurer.

1. Amendment of section and NOTE filed 1-8-2008; operative 2-7-2008 (Register 2008, No. 2).
2. Amendment of section heading and section filed 1-30-2015 as an emergency; operative 1-30-2015 (Register 2015, No. 5). A Certificate of Compliance must be transmitted to OAL by 7-29-2015 or emergency language will be repealed by operation of law on the following day.
3. Amendment of section heading and section refiled 7-27-2015 as an emergency; operative 7-27-2015 (Register 2015, No. 31). A Certificate of Compliance must be transmitted to OAL by 10-26-2015 or emergency language will be repealed by operation of law on the following day.
4. Amendment of section heading and section refiled 10-26-2015 as an emergency; operative 10-26-2015 (Register 2015, No. 44). A Certificate of Compliance must be transmitted to OAL by 1-25-2016 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 10-26-2015 order, including amendment of subsections (b) and (d) and new subsection (e), transmitted to OAL 1-25-2016 and filed 3-8-2016; amendments operative 3-8-2016 pursuant to Government Code section 11343.4(b)(3) (Register 2016, No. 11).

Note: Authority cited: Section 10133.5, Insurance Code. Reference: Sections 10133 and 10133.5, Insurance Code.

Disclaimer: These regulations may not be the most recent version. California may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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