Current through Register Vol. 39, No. 6, September 16, 2024
(a) As
used in this Rule:
(1) "Health benefit plan"
means any accident and health insurance policy or certificate; a nonprofit
hospital or medical service corporation contract; a health maintenance
organization subscriber contract; a plan provided by a multiple employer
welfare arrangement; or a plan provided by another benefit
arrangement.
(2) "Health care
provider" includes any person who, under Chapter 90 of the General Statutes is
licensed, registered, or certified to engage in the practice of or performs
duties associated with any of the following: medicine, surgery, dentistry,
pharmacy, optometry, midwifery, osteopathy, podiatry, chiropractic, radiology,
nursing, physiotherapy, pathology, anesthesiology, anesthesia, laboratory
analysis, rendering assistance to a physician, dental hygiene, psychiatry,
psychology; or a hospital as defined by
G.S.
131E-76(3); or a nursing
home as defined by
G.S.
131E-101(6).
(3) "Health insurer" means any health
insurance company subject to Articles 1 through 63 of Chapter 58, including a
multiple employer welfare arrangement; any preferred provider plan; and any
corporation subject to Articles 65 and 67 of Chapter 58; that provides a health
benefit plan.
(b) If
health insurers enter into contracts with health care providers for the
provision of health care services at discounted rates of payment (including
capitated and other alternative negotiated rates), and applicable deductibles
or copayments paid by insureds are to be based upon a percentage of the fees
for services rendered, the amounts of deductibles and copayments shall be
computed based on such rates for the services rendered when such rates are less
than the provider's ordinary charges for the services rendered.
(c) The following are deemed to be unfair and
deceptive acts and practices in the business of insurance:
(1) Attempting to settle a claim or
attempting to charge or to collect or charging or collecting copayments in
amounts greater than those calculated in accordance with this Rule.
(2) Attempting to pay or settle or paying or
settling a claim based upon the calculation of a deductible that is not
calculated in accordance with this Rule.
(3) Attempting to calculate or calculating an
annual, calendar, or lifetime maximum amount payable on any amounts other than
as set forth in this Rule.
(4)
Attempting to settle a claim involved in coordination of benefits in any manner
not in accordance with this Rule.
(5) Attempting to collect a claim against a
stop-loss or excess health insurer in any manner inconsistent with this
Rule.
(d) Negotiating
discounts with health care providers based upon the total volume of services
and that is settled on a retrospective basis in which the discounts are not
attributed to individual claimants, is not deemed to be an unfair and deceptive
act or practice in the business of insurance.
Authority
G.S.
58-2-40;
58-50-55;
58-63-65;
58-65-1;
58-65-40;
58-65-140;
58-67-150;
Eff.
January 1, 1995;
Pursuant to
G.S.
150B-21.3A, rule is necessary without
substantive public interest Eff. May 1, 2018.
