| (G) the published product name and version of any software
the HMO uses to determine bundling and unbundling of claims.
(2) In the case of a reference to source information
outside the control of the HMO as the basis for fee computation, such
as state Medicaid or federal Medicare fee schedules, the information
the HMO provides must clearly identify the source and explain the
procedure by which the physician or provider may readily access the
source electronically, telephonically, or as otherwise agreed to by
the parties.
(3) Nothing in this subsection may be construed to
require an HMO to provide specific information that would violate
any applicable copyright law or licensing agreement. However, the
HMO must supply, instead of any information withheld on the basis
of copyright law or licensing agreement, a summary of the information
that will allow a reasonable person with sufficient training, experience,
and competence in claims processing to determine the payment to be
made under the terms of the contract for covered services that are
rendered to enrollees as required by paragraph (1) of this subsection.
(4) No amendment, revision, or substitution of any
of the claims payment procedures or any of the information required
to be provided by this subsection will be effective as to the contracting
physician or provider, unless the HMO provides at least 90-calendar-days
written notice to the contracting physician or provider identifying
with specificity the amendment, revision, or substitution. An HMO
may not make retroactive changes to claims payment procedures or any
of the information required to be provided by this subsection. Where
a contract specifies mutual agreement of the parties as the sole mechanism
for requiring amendment, revision, or substitution of the information
required by this subsection, the written notice specified in this
section does not supersede the requirement for mutual agreement.
(5) The HMO must provide the information required by
paragraphs (1) - (4) of this subsection to the contracting physician
or provider by the 30th day after the date the HMO receives the contracting
physician's or provider's request.
(6) A physician or provider receiving information under
this subsection may not:
(A) use or disclose the information for any purpose
other than:
(i) the physician's or provider's practice management,
(ii) billing activities,
(iii) other business operations, or
(iv) communications with a governmental agency involved
in the regulation of health care or insurance;
(B) use the information to knowingly submit a claim
for payment that does not accurately represent the level, type, or
amount of services that were actually provided to an enrollee or to
misrepresent any aspect of the services; or
(C) rely on information provided under this paragraph
about a service as a representation that an enrollee is covered for
that service under the terms of the enrollee's evidence of coverage.
(7) A physician or provider that receives information
under this subsection may terminate the contract on or before the
30th day after the date the physician or provider receives the information
without penalty or discrimination in participation in other health
care products or plans. The contract between the HMO and physician
or provider must provide for reasonable advance notice to enrollees
being treated by the physician or provider before the termination
consistent with Insurance Code §843.309.
(8) The provisions of this subsection may not be waived,
voided, or nullified by contract.
(d) Physician and provider contracts, subcontracts,
and arrangements must include provisions regarding written notification
of termination to a physician or provider in compliance with Insurance
Code §843.306 (concerning Termination of Participation; Advisory
Review Panel) and §843.307 (concerning Expedited Review Process
on Termination or Deselection), including provisions providing that:
(1) the HMO must provide notice of termination by the
HMO to the physician or provider at least 90 days before the effective
date of the termination;
(2) not later than 30 days following receipt of the
written notification of termination, a physician or provider may request
a review by the HMO's advisory review panel except in a case involving:
(A) imminent harm to patient health;
(B) an action by a state medical or dental board, another
medical or dental licensing board, or another licensing board or government
agency that effectively impairs the physician's or provider's ability
to practice medicine, dentistry, or another profession; or
(C) fraud or malfeasance; and
(3) within 60 days after receipt of the physician or
provider's request for review, the advisory review panel must make
its formal recommendation and the HMO must communicate its decision
to the physician or provider.
(e) On request by a participating physician or provider,
an HMO must include a provision in the physician's or provider's contract
providing that the HMO and the HMO's clearinghouse may not refuse
to process or pay an electronically submitted clean claim because
the claim is submitted together with or in a batch submission with
a claim that is deficient. As used in this section, the term "batch
submission" means "a group of electronic claims submitted for processing
at the same time within a Health Insurance Portability and Accountability
Act (HIPAA) standard ASC X12N 837 Transaction Set and identified by
a batch control number." This subsection applies to a contract entered
into or renewed on or after the effective date of this subsection.
For a contract entered into or renewed before the effective date of
this subsection, the law and regulations in effect at the time the
contract was entered or renewed, whichever is later, governs.
(f) A contract between an HMO and a dentist may not
limit the fee the dentist may charge for a service that is not a covered
service under Insurance Code §843.3115 (concerning Contracts
with Dentists).
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