Chapter 695G - Managed Care
- ADMINISTRATION OF MANAGED CARE ORGANIZATIONS
- 695G.110 - Medical director must be physician licensed in this State.
- 695G.120 - Utilization review: Written policies and procedures; subcontracting.
- 695G.125 - Contracts with certain federally qualified health centers.
- 695G.130 - Report regarding methods for reviewing quality of health care services: Requirements; availability for public inspection.
- COVERAGE BY MANAGED CARE ORGANIZATIONS
- 695G.150 - Authorization of recommended and covered health care services required.
- 695G.160 - Written criteria concerning coverage of health care services and standards for quality of health care services.
- 695G.163 - Coverage for prescription drugs: Provision of notice and information regarding use of formulary.
- 695G.164 - Required provision concerning coverage for continued medical treatment.
- 695G.1645 - Required provision concerning coverage for autism spectrum disorders. [Effective January 1, 2011.]
- 695G.166 - Required provision concerning coverage for prescription drug previously approved for medical condition of insured.
- 695G.168 - Required provision concerning coverage for screening for colorectal cancer.
- 695G.170 - Required provision concerning coverage for medically necessary emergency services; prohibitions.
- 695G.171 - Required provision concerning coverage for human papillomavirus vaccine.
- 695G.173 - Required provision concerning coverage for treatment received as part of clinical trial or study.
- 695G.175 - Certain actions of managed care organization prohibited.
- 695G.177 - Required provision concerning coverage for prostate cancer screening.
- EXTERNAL REVIEW OF ADVERSE DETERMINATION
- 695G.241 - Adverse determination deemed final for purpose of submitting to external review organization.
- 695G.251 - Request for review; assignment of external review organization; provision of documents relating to adverse determination to external review organization.
- 695G.261 - Review of documents by external review organization; decision of external review organization.
- 695G.271 - Expedited approval or denial of request.
- 695G.280 - Basis for decision of external review organization.
- 695G.290 - Decision in favor of insured binding on managed care organization; limitation of liability; cost for external review organization.
- 695G.300 - Submission of complaint of insured to external review organization.
- 695G.310 - Annual report; requirements.
- GENERAL PROVISIONS
- 695G.010 - Definitions.
- 695G.012 - “Adverse determination” defined.
- 695G.014 - “Authorized representative” defined.
- 695G.016 - “Clinical peer” defined.
- 695G.018 - “External review organization” defined.
- 695G.020 - “Health care plan” defined.
- 695G.030 - “Insured” defined.
- 695G.040 - “Managed care” defined.
- 695G.050 - “Managed care organization” defined.
- 695G.055 - “Medically necessary” defined.
- 695G.060 - “Primary care physician” defined.
- 695G.070 - “Provider of health care” defined.
- 695G.080 - “Utilization review” defined.
- 695G.090 - Applicability. [Effective through December 31, 2010.]
- 695G.095 - Offering policy of health insurance for purposes of establishing health savings account.
- PROHIBITED ACTS
- 695G.400 - Managed care organization prohibited from interfering in or restricting certain communications.
- 695G.405 - Managed care organization prohibited from denying coverage solely because insured was intoxicated or under the influence of controlled substance; exceptions.
- 695G.410 - Certain actions taken against provider solely because provider advocates on behalf of patient, assists patient or reports violation of law prohibited.
- 695G.420 - Offering or paying financial incentive to provider to deny, reduce, withhold, limit or delay medically necessary services prohibited.
- 695G.430 - Contracts between managed care organization and provider of health care: Form for obtaining information on provider of health care; modification; schedule of fees.
- QUALITY ASSURANCE PROGRAM
- SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS
- 695G.200 - Approval; requirements; assistance for persons filing complaints; examination.
- 695G.210 - Review board; appeal; right to expedited review of complaint; notice to insured.
- 695G.220 - Annual report; managed care organization to maintain records of complaints concerning something other than health care services.
- 695G.230 - Written notice to insured explaining rights of insureds regarding decision to deny coverage; notice to insured when organization denies coverage of health care service.