36-2923

36-2923. Insurer claims data reporting
requirements; administration as payor of last resort; report;
definition

A. A health care insurer shall:

1. Provide all enrollment information necessary to determine the time period in
which a person who is defined as an eligible person pursuant to section 36-2901,
paragraph 6, subdivision (a) or that person's spouse or dependents may be or may have
been covered by the health care insurer and the nature of that coverage. The information
shall be provided to the administration in the manner prescribed by the secretary of the
United States department of health and human services or in a manner agreed to between
the health care insurer and the administration.

2. Accept the state's right of recovery from a third party payor pursuant to
section 36-2903 and the assignment to this state of any right of an individual or other
entity to payment from the third party payor for an item or service for which payment has
been made pursuant to this chapter. This paragraph does not expand the scope of
coverage, benefits or rights under the policy issued by the health care insurer.

3. Respond to any inquiry made by the director regarding a claim for payment for
any health care item or service that is submitted not later than three years after the
date of the provision of the health care item or service. This paragraph applies to a
claim in which the administration determines there is a reasonable belief that the
individual was insured by the health care insurer on the date of service referenced by
the claim.

4. Not deny a claim submitted by this state solely on the basis of the date of the
submission of the claim, the type or format of the claim form or the failure to present
proper documentation at the point of sale that is the basis of the claim if the following
conditions have been met:

(a) The claim is submitted by this state in the three-year period beginning on the
date on which the item or service was furnished.

(b) An action by this state to enforce its rights with respect to the claim is
commenced within six years after the state submitted the claim. The health care insurer
may deny the claim submitted by the state if the health care insurer has already paid the
claim in accordance with the benefit plan under which the member was covered by the
health care insurer on the date of service.

B. On or before January 1 of each year, the director shall publish a report on
health care insurer compliance with the claims data reporting requirements of this
section. The report shall include the following:

1. A list of each health care insurer that has not materially complied with the
requirements of this section.

2. Corrective actions, if any, that health care insurers have taken to comply with
the requirements of this section.

C. The director shall submit a copy of each report to the governor, the president
of the senate and the speaker of the house of representatives and shall provide a copy of
each report to the secretary of state and the director of the Arizona state library,
archives and public records.

D. Any information obtained by the director or the administration under this
section shall be maintained as confidential as required by the health insurance
portability and accountability act of 1996 (P.L. 104-191; 110 Stat. 1936) and other
applicable law and shall be used solely for the purpose of determining whether a health
care insurer was also providing coverage to an individual during the period that the
individual was an eligible member, for the purposes of avoiding payments by the system
for services covered through other insurance and for enforcing the administration's right
to assignment under subsection A of this section.

E. For the purposes of this section, "health care insurer" means a self-insured
health benefit plan, a group health plan as defined in section 607(1) of the employment
retirement income security act of 1974, a pharmacy benefit manager or any other party
that by statute, contract or agreement is responsible for paying for items or services
provided to an eligible person under this chapter, including:

1. An entity transacting disability insurance as defined in section 20-253.

2. Hospital service corporations, medical service corporations, dental service
corporations, optometric service corporations and hospital, medical, dental and
optometric service corporations as defined in section 20-822.

3. A prepaid dental plan organization as defined in section 20-1001.

4. A health care services organization as defined in section 20-1051.

5. An entity transacting group disability insurance pursuant to section 20-1401.

6. An entity transacting blanket disability insurance pursuant to section 20-1404.