Current through 2024-38, September 18, 2024
1. Upon receipt of a
claim for covered emergency services rendered by an out-of-network provider, a
carrier shall:
A. pay the claim based on an
allowable charge calculated in accordance with paragraph B, unless the carrier
and provider negotiate a different amount or the patient knowingly elected to
obtain the services from an out-of-network provider. The carrier shall pay the
allowable charge to the provider, subject to the following adjustments:
(1) Payment shall be made net of the
coinsurance, copayment, deductible, and any other out-of-pocket expense for
which the enrollee is responsible under subsection
3;
(2) To the extent that the enrollee has paid
the provider more than the cost sharing required by subparagraph (1), the
carrier shall pay the excess to the enrollee and deduct that amount from the
payment otherwise due to the provider;
(3) Payment shall be made net of any amounts
already paid by the carrier; and
(4) If the carrier is a secondary payer, the
enrollee's and carrier's responsibility shall be reduced as called for by
applicable coordination of benefits procedures;
B. determine the total amount the provider is
entitled to receive for health care services rendered. The carrier's
determination of median network rates shall be based on the CPT code for the
claim and the geographic rating area in which the service was rendered, unless
the carrier determines that the available data are insufficient or otherwise
inapplicable, in which case the carrier, subject to the process of negotiation
and IDR review, may use a broader geographic area or bundle of CPT codes. The
provider's allowable charge shall be the greater of:
(1) the carrier's median network rate paid
for the service by a similar provider in the geographic area in which the
service was rendered; and
(2) the
median network rate paid by all carriers for that health care service by a
similar provider in the geographic area in which the service was rendered as
determined by the all-payer claims database maintained by the Maine Health Data
Organization or, if Maine Health Data Organization claims data is insufficient
or otherwise inapplicable, another independent medical claims database
specified by the Superintendent after consulting with interested
parties.
C. give notice
to the provider, in a form and manner prescribed by the Superintendent,
specifying the carrier's allowable charge for the service, and describing how
the provider may initiate the IDR process if the carrier and provider are
unable to reach agreement within 30 days;
D. if the carrier pays an amount less than
the provider's charge, provide the enrollee with notice which shall explain
that the enrollee shall incur no greater out-of-pocket costs for the services
than the enrollee would have incurred with a network provider. The carrier may
provide this notice on or with the explanation of benefits required under
24-A M.R.S.
§4303(13);
and
E. direct the enrollee to
contact the carrier if the provider bills the enrollee for the out-of-network
service for more than the amount indicated as the enrollee's responsibility on
the carrier's explanation of benefits.
2. A carrier shall prominently post on its
website the following information regarding surprise bills and bills for
emergency services rendered by out-of-network providers, and include the same
information in disclosure materials provided to enrollees:
A. a description of what constitutes a
surprise bill;
B. an explanation of
which surprise bills are eligible for the IDR process;
C. a description of the IDR
process;
D. information on how an
out-of-network provider may submit a dispute for resolution by an
IDRE.
3. A carrier shall
ensure that the enrollee does not incur any greater out-of-pocket costs for the
services than the enrollee would have incurred with a provider charging the
carrier's median network rate. The carrier may not increase the enrollee's
coinsurance if negotiation or IDR results in an increase in the applicable
network rate.
4. If an IDRE directs
a carrier to engage in negotiations with an out-of-network provider, the IDRE
shall specify a time period for negotiation, not to exceed ten business days,
and the parties shall negotiate in good faith. If a settlement is reached, the
carrier shall notify the IDRE of the settlement within two business days and
shall make any additional payment to the provider within thirty days. If a
settlement is not reached or the parties agree that a settlement is not
attainable, the carrier shall promptly notify the IDRE within the period
granted by the IDRE for negotiation.
5. If the IDRE issues a determination in
favor of the provider, the carrier shall pay the provider any additional amount
owed within 30 days after the date of the determination.
6. A carrier shall designate, and identify to
the Superintendent, someone knowledgeable about the IDR process who shall be
responsible for oversight of the carrier's compliance with the process. The
carrier shall make at least one staff member available full time during normal
business hours. The carrier shall respond to all inquiries from the
Superintendent relating to the IDR process within five business days.
7. A self-insured employer or the
administrator of a self-insured health benefit plan may elect to be treated as
a carrier under this rule by filing a notice in a form and manner
prescribed by the Superintendent as provided in this subsection. The
plan's rights and responsibilities as a carrier apply to all services provided
to enrollees after the notice of participation is received by the
Superintendent, unless the plan requests a different effective date. In order
for the plan's participating status to remain in effect without interruption, a
renewal notice must be received before the expiration of the plan year. The
initial and renewal notices must include the following:
A. the identity and contact information of
the self-insured employer and the plan administrator;
B. an agreement to submit to the jurisdiction
of the Superintendent and to be bound by the requirements of this rule, the
applicable provisions of the Maine Insurance Code, and any order or decision
made by an IDRE pursuant to this rule; and
C. evidence that the plan documents have been
amended to reflect the applicability of the IDR process to the plan's
enrollees.
