| (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.
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