| (a) When services are rendered to an enrollee by a
non-network facility-based physician in a network facility, or in
circumstances where an enrollee is not given the choice of a network
physician or provider, the HMO must fully reimburse the non-network
facility-based physician or provider at the usual and customary rate
as described in subsection (e) of this section or at an agreed rate.
(b) In circumstances where an enrollee receives emergency
care in a non-network facility, the HMO must fully reimburse a non-network
physician or provider for emergency care services at the usual and
customary rate as described in subsection (e) of this section or at
an agreed rate until the enrollee can reasonably be expected to transfer
to a network physician or provider.
(c) If medically necessary covered services, other
than emergency care, are not available through a network physician
or provider on the request of a network physician or provider, the
HMO must:
(1) approve a referral to a non-network physician or
provider within the time appropriate to the circumstances relating
to the delivery of the services and the condition of the patient,
but in no event to exceed five business days after receipt of reasonably
requested documentation; and
(2) provide for a review by a physician or provider
with expertise in the same specialty as or a specialty similar to
the type of health care physician or provider to whom a referral is
requested under paragraph (1) of this subsection before the HMO may
deny the referral.
(d) An HMO reimbursing a non-network physician or provider
providing services under subsection (a), (b), or (c) of this section
must ensure that the enrollee is held harmless for any amounts beyond
the copayment or other out-of-pocket amounts that the enrollee would
have paid had the HMO network included network physicians or providers
from whom the enrollee could obtain the services.
(e) After determining that a claim from a non-network
physician or provider for services provided under subsection (a),
(b), or (c) of this section is payable, an HMO must issue payment
to the non-network physician or provider at the usual and customary
rate or at a rate agreed to by the HMO and the non-network physician
or provider. If the rate was not agreed to by the physician or provider,
the HMO must provide an explanation of benefits to the enrollee that
includes a statement that the HMO's payment is at least equal to the
usual and customary rate for the service, that the enrollee should
notify the HMO if the non-network physician or provider bills the
enrollee for amounts beyond the amount paid by the HMO, of the procedures
for contacting the HMO on receipt of a bill from the non-network physician
or provider for amount beyond the amount paid by the HMO, and the
number for the department's Consumer Protection Section for complaints
regarding payment.
(f) Any methodology used by an HMO to calculate reimbursements
of non-network physicians or providers for covered services not available
from network physicians or providers must comply with the following:
(1) if based on usual and customary charges, then the
methodology must be based on generally accepted industry standards
and practices for determining the customary billed charge for a service,
and fairly and accurately reflect market rates, including geographic
differences in costs;
(2) if based on claims data, then the methodology must
be based on sufficient data to constitute a representative and statistically
valid sample;
(3) any claims data underlying the calculation must
be updated no less than once per year and not include data that is
more than three years old; and
(4) the methodology must be consistent with nationally
recognized and generally accepted bundling edits and logic.
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