North Carolina Administrative Code
Title 11 - INSURANCE
Chapter 12 - LIFE AND HEALTH DIVISION
Section .1500 - UNIFORM CLAIM FORMS
Section 12 .1505 - MANAGED CARE FORMS
Universal Citation: 11 NC Admin Code 12 .1505
Current through Register Vol. 39, No. 6, September 16, 2024
(a) As used in this Rule, "managed care plan" includes a health maintenance organization or a preferred provider organization.
(b) The following managed care forms may be used by managed care plans, but shall not be a part of the standard claim form:
(1) An "out-of-network" justification form
shall be used by patients filing claims with their managed care plans when they
have to justify the reasons they sought out-of-network health care services.
This form shall be standardized, and the managed care plan industry shall
develop and file this form with the Commissioner.
(2) A "patient encounter form and electronic
format" shall be used by managed care plans to record and report encounter
information. This form shall provide information similar to the CMS Form 1450
(UB-04) and CMS Form 1500 and shall include information on patient
identification, dates of services provided, types of services provided, and
identities of health care providers. This form and electronic formats shall be
standardized, and the managed care plan industry shall develop and file these
with the Commissioner.
Authority
G.S.
58-2-40;
58-3-171;
Eff. October
1, 1994;
Readopted Eff. May 1,
2020.
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