Current through Reg. 50, No. 13; March 28, 2025
(a) Access to designation as a preferred
provider. Physicians, practitioners, institutional providers, and health care
providers other than physicians, practitioners, and institutional providers, if
other health care providers are included by an insurer as preferred providers,
that are licensed to treat injuries or illnesses or to provide services covered
by the preferred provider benefit plan and that comply with the terms and
conditions established by the insurer for designation as preferred providers,
are eligible to apply for and must be afforded a fair, reasonable, and
equitable opportunity to become preferred providers, subject to subsection (b)
of this section.
(1) An insurer initially
sponsoring a preferred provider benefit plan is required to notify all
physicians and practitioners in the service area covered by the plan of its
intent to offer the plan and of the opportunity to apply to
participate.
(2) Subsequently, an
insurer is required to annually notify all non-contracting physicians and
practitioners in the service area covered by the plan of the existence of the
plan and the opportunity to apply to participate in the plan.
(3) An insurer is required, upon request, to
make available to any physician or provider information concerning the
application process and qualification requirements, including the use of
economic profiling by the insurer, used by the insurer to admit a provider to
the plan.
(4) All notifications
required to be made by an insurer pursuant to this subsection are required to
be made by publication or distributed in writing to each physician and
practitioner in the same manner.
(5) Selection standards used by the insurer
in choosing participating preferred providers must not directly or indirectly:
(A) avoid high risk populations by excluding
physicians or providers because the physicians or providers are located in
geographic areas that contain populations presenting a risk of higher than
average claims, losses or health services utilization; or
(B) exclude a physician or provider because
the physician or provider treats or specializes in treating populations
presenting a risk of higher than average claims, losses or health services
utilization.
(b) Withholding preferred provider
designation. An insurer may not unreasonably withhold designation as a
preferred provider except that, unless otherwise limited by the Insurance Code
or rule promulgated by the department, an insurer may reject an application
from a physician or health care provider on the basis that the preferred
provider benefit plan has sufficient qualified providers.
(1) An insurer is required to provide written
notice of denial of any initial application to a physician or health care
provider, which includes:
(A) the specific
reason(s) for the denial; and
(B)
in the case of physicians and practitioners, the right to a review of the
denial as set forth in paragraph (2) of this subsection.
(2) An insurer must provide a reasonable
review mechanism that incorporates, in an advisory role only, a review panel.
(A) The advisory review panel is required to
be composed of not less than three individuals selected by the insurer from the
list of physicians or practitioners in the applicable service area contracting
with the insurer.
(B) At least one
of the three individuals on the advisory review panel must be a physician or
practitioner in the same or similar specialty as the physician or practitioner
requesting review unless there is no physician or practitioner in the same or
similar specialty contracting with the insurer.
(C) The list of physicians or practitioners
required by subparagraph (A) of this paragraph is required to be provided to
the insurer by the physicians or practitioners who contract with the insurer in
the applicable service area.
(D)
The recommendation of the advisory review panel is required to be provided upon
request to the affected physician or practitioner.
(E) In the event that the insurer makes a
determination that is contrary to the recommendation of the advisory review
panel, a written explanation of the insurer's determination is required to be
provided to the affected physician or practitioner upon request.
(c) Credentialing of
preferred providers. Insurers must have a documented process for selection and
retention of preferred providers sufficient to ensure that preferred providers
are adequately credentialed. At a minimum, an insurer's credentialing standards
must meet the standards promulgated by the National Committee for Quality
Assurance (NCQA) or URAC to the extent that those standards do not conflict
with other laws of this state. Insurers will be presumed to be in compliance
with statutory and regulatory requirements regarding credentialing if they have
received nonconditional accreditation or certification by the NCQA, the Joint
Commission, URAC, or the Accreditation Association for Ambulatory Health
Care.
(d) Notice of termination of
a preferred provider contract. Before terminating a contract with a preferred
provider, the insurer must provide written notice of termination, which
includes:
(1) the specific reason(s) for the
termination; and
(2) in the case of
physicians or practitioners, notice of the right to request a review prior to
termination that is conducted in the same manner as the review mechanism set
forth in subsection (b)(2) of this section and that complies with the timelines
set forth in subsections (e) - (h) of this section for requesting review,
except in cases involving:
(A) imminent harm
to patient health;
(B) an action by
a state medical or other physician licensing board or other government agency
which impairs the physician's or practitioner's ability to practice medicine or
to provide services; or
(C) fraud
or malfeasance.
(e) Review of a decision to terminate. To
obtain a standard review of an insurer's decision to terminate him or her, a
physician or practitioner must:
(1) make a
written request to the insurer for a review of that decision within 10 business
days of receipt of notification of the insurer's intent to terminate him or
her; and
(2) deliver to the
insurer, within 20 business days of receipt of notification of the insurer's
intent to terminate him or her, any relevant documentation the physician or
practitioner desires the advisory review panel and insurer to consider in the
review process.
(f)
Completion of the review process. The review process, including the
recommendation of the advisory review panel and the insurer's determination as
required by subsection (b)(2)(E) of this section, must be completed and the
results provided to the physician or practitioner within 60 calendar days of
the insurer's receipt of the request for review.
(g) Expedited review process. To obtain an
expedited review of an insurer's decision to terminate him or her, a physician
or practitioner must:
(1) make a written
request to the insurer for a review of that decision within five business days
of receipt of notification of the insurer's intent to terminate him or her;
and
(2) deliver to the insurer,
within 10 business days of receipt of notification of the insurer's intent to
terminate him or her, any relevant documentation the physician or practitioner
desires the advisory review panel and insurer to consider in the review
process.
(h) Completion
of the expedited review process. The expedited review process, including the
recommendation of the advisory review panel and the insurer's determination as
required by subsection (b)(2)(E) of this section, must be completed and the
results provided to the physician or practitioner within 30 calendar days of
the insurer's receipt of the request for review.
(i) Confidentiality of information concerning
the insured.
(1) An insurer is required to
preserve the confidentiality of individual medical records and personal
information used in its termination review process. Personal information of the
insured includes, at a minimum, the insured's name, address, telephone number,
social security number, and financial information.
(2) An insurer may not disclose or publish
individual medical records or other confidential information about an insured
without the prior written consent of the insured or unless otherwise required
by law. An insurer may provide confidential information to the advisory review
panel for the sole purpose of performing its advisory review function.
Information provided to the advisory review panel is required to remain
confidential.
(j) Notice
to insureds.
(1) If the contract of a
physician or practitioner is terminated for reasons other than at the preferred
provider's request, an insurer may not notify insureds of the termination until
the effective date of the termination or at such time as an advisory review
panel makes a formal recommendation regarding the termination, whichever is
later.
(2) If a physician or
provider voluntarily terminates the physician's or provider's relationship with
an insurer, the insurer must provide assistance to the physician or provider in
assuring that the notice requirements are met as required by §
3.3703(a)(18) of
this title (relating to Contracting Requirements).
(3) If the contract of a physician or
practitioner is terminated for reasons related to imminent harm, an insurer may
notify insureds immediately.
