§ 58‑3‑191. Managed care reporting and disclosure requirements.
(a) Each health benefitplan shall annually, on or before the first day of May of each year, file inthe office of the Commissioner the following information for the previouscalendar year:
(1) The number of andreasons for grievances received from plan participants regarding medicaltreatment. The report shall include the number of covered lives, total numberof grievances categorized by reason for the grievance, the number of grievancesreferred to the second level grievance review, the number of grievancesresolved at each level and their resolution, and a description of the actionsthat are being taken to correct the problems that have been identified throughgrievances received. Every health benefit plan shall file with theCommissioner, as part of its annual grievance report, a certificate ofcompliance stating that the carrier has established and follows, for each ofits lines of business, grievance procedures that comply with G.S. 58‑50‑62.
(2) The number ofparticipants and groups who terminated coverage under the plan for any reason.The report shall include the number of participants who terminated coveragebecause the group contract under which they were covered was terminated, the numberof participants who terminated coverage for reasons other than the terminationof the group under which they were enrolled, and the number of group contractsterminated.
(3) The number ofprovider contracts that were terminated and the reasons for termination. Thisinformation shall include the number of providers leaving the plan and thenumber of new providers. The report shall show voluntary and involuntaryterminations separately.
(4) Data relating to theutilization, quality, availability, and accessibility of services. The reportshall include the following:
a. Information on thehealth benefit plan's program to determine the level of network availability,as measured by the numbers and types of network providers, required to providecovered services to covered persons. This information shall include the plan'smethodology for:
1. Establishingperformance targets for the numbers and types of providers by specialty, areaof practice, or facility type, for each of the following categories: primary carephysicians, specialty care physicians, nonphysician health care providers,hospitals, and nonhospital health care facilities.
2. Determining whenchanges in plan membership will necessitate changes in the provider network.
Thereport shall also include: the availability performance targets for theprevious and current years; the numbers and types of providers currentlyparticipating in the health benefit plan's provider network; and an evaluationof actual plan performance against performance targets.
b. The health benefitplan's method for arranging or providing health care services from nonnetworkproviders, both within and outside of its service area, when network providersare not available to provide covered services.
c. Information on thehealth benefit plan's program to determine the level of provider networkaccessibility necessary to serve its membership. This information shall includethe health benefit plan's methodology for establishing performance targets formember access to covered services from primary care physicians, specialty carephysicians, nonphysician health care providers, hospitals, and nonhospitalhealth care facilities. The methodology shall establish targets for:
1. The proximity ofnetwork providers to members, as measured by member driving distance, to accessprimary care, specialty care, hospital‑based services, and services ofnonhospital facilities.
2. Expected waitingtime for appointments for urgent care, acute care, specialty care, and routineservices for prevention and wellness.
Thereport shall also include: the accessibility performance targets for theprevious and current years; data on actual overall accessibility as measured bydriving distance and average appointment waiting time; and an evaluation ofactual plan performance against performance targets. Measures of actualaccessibility may be developed using scientifically valid random sampletechniques.
d. A statement of thehealth benefit plan's methods and standards for determining whether in‑networkservices are reasonably available and accessible to a covered person, for thepurpose of determining whether a covered person should receive the in‑networklevel of coverage for services received from a nonnetwork provider.
e. A description of thehealth benefit plan's program to monitor the adequacy of its networkavailability and accessibility methodologies and performance targets, planperformance, and network provider performance.
f. A summary of thehealth benefit plan's utilization review program activities for the previouscalendar year. The report shall include the number of: each type of utilizationreview performed, noncertifications for each type of review, each type ofreview appealed, and appeals settled in favor of covered persons. The reportshall be accompanied by a certification from the carrier that it hasestablished and follows procedures that comply with G.S. 58‑50‑61.
(5) Aggregate financialcompensation data, including the percentage of providers paid under acapitation arrangement, discounted fee‑for‑service or salary, theservices included in the capitation payment, and the range of compensation paidby withhold or incentive payments. This information shall be submitted on aform prescribed by the Commissioner.
The name, or group orinstitutional name, of an individual provider may not be disclosed pursuant tothis subsection. No civil liability shall arise from compliance with theprovisions of this subsection, provided that the acts or omissions are made ingood faith and do not constitute gross negligence, willful or wantonmisconduct, or intentional wrongdoing.
(b) Disclosurerequirements. Each health benefit plan shall provide the following applicableinformation to plan participants and bona fide prospective participants uponrequest:
(1) The evidence ofcoverage (G.S. 58‑67‑50), subscriber contract (G.S. 58‑65‑60,58‑65‑140), health insurance policy (G.S. 58‑51‑80, 58‑50‑125,58‑50‑126, 58‑50‑55), or the contract and benefitsummary of any other type of health benefit plan;
(2) An explanation ofthe utilization review criteria and treatment protocol under which treatmentsare provided for conditions specified by the prospective participant. Thisexplanation shall be in writing if so requested;
(3) If denied arecommended treatment, written reasons for the denial and an explanation of theutilization review criteria or treatment protocol upon which the denial wasbased;
(4) The plan'sformularies, restricted access drugs or devices as defined in G.S. 58‑3‑221,or prior approval requirements for obtaining prescription drugs, whether aparticular drug or therapeutic class of drugs is excluded from its formulary,and the circumstances under which a nonformulary drug may be covered; and
(5) The plan'sprocedures and medically based criteria for determining whether a specifiedprocedure, test, or treatment is experimental.
(b1) Effective March 1,1998, insurers shall make the reports that are required under subsection (a) ofthis section and that have been filed with the Commissioner available on theirbusiness premises and shall provide any insured access to them upon request.
(c) For purposes ofthis section, "health benefit plan" or "plan" means (i)health maintenance organization (HMO) subscriber contracts and (ii) insurancecompany or hospital and medical service corporation preferred provider benefitplans as defined in G.S. 58‑50‑56. (1997‑480, s. 1; 1997‑519, s. 1.1; 2001‑334,s. 2.2; 2001‑446, s. 2.1; 2006‑154, s. 13; 2008‑124, s.10.1.)
§ 58‑3‑191. Managed care reporting and disclosure requirements.
(a) Each health benefitplan shall annually, on or before the first day of May of each year, file inthe office of the Commissioner the following information for the previouscalendar year:
(1) The number of andreasons for grievances received from plan participants regarding medicaltreatment. The report shall include the number of covered lives, total numberof grievances categorized by reason for the grievance, the number of grievancesreferred to the second level grievance review, the number of grievancesresolved at each level and their resolution, and a description of the actionsthat are being taken to correct the problems that have been identified throughgrievances received. Every health benefit plan shall file with theCommissioner, as part of its annual grievance report, a certificate ofcompliance stating that the carrier has established and follows, for each ofits lines of business, grievance procedures that comply with G.S. 58‑50‑62.
(2) The number ofparticipants and groups who terminated coverage under the plan for any reason.The report shall include the number of participants who terminated coveragebecause the group contract under which they were covered was terminated, the numberof participants who terminated coverage for reasons other than the terminationof the group under which they were enrolled, and the number of group contractsterminated.
(3) The number ofprovider contracts that were terminated and the reasons for termination. Thisinformation shall include the number of providers leaving the plan and thenumber of new providers. The report shall show voluntary and involuntaryterminations separately.
(4) Data relating to theutilization, quality, availability, and accessibility of services. The reportshall include the following:
a. Information on thehealth benefit plan's program to determine the level of network availability,as measured by the numbers and types of network providers, required to providecovered services to covered persons. This information shall include the plan'smethodology for:
1. Establishingperformance targets for the numbers and types of providers by specialty, areaof practice, or facility type, for each of the following categories: primary carephysicians, specialty care physicians, nonphysician health care providers,hospitals, and nonhospital health care facilities.
2. Determining whenchanges in plan membership will necessitate changes in the provider network.
Thereport shall also include: the availability performance targets for theprevious and current years; the numbers and types of providers currentlyparticipating in the health benefit plan's provider network; and an evaluationof actual plan performance against performance targets.
b. The health benefitplan's method for arranging or providing health care services from nonnetworkproviders, both within and outside of its service area, when network providersare not available to provide covered services.
c. Information on thehealth benefit plan's program to determine the level of provider networkaccessibility necessary to serve its membership. This information shall includethe health benefit plan's methodology for establishing performance targets formember access to covered services from primary care physicians, specialty carephysicians, nonphysician health care providers, hospitals, and nonhospitalhealth care facilities. The methodology shall establish targets for:
1. The proximity ofnetwork providers to members, as measured by member driving distance, to accessprimary care, specialty care, hospital‑based services, and services ofnonhospital facilities.
2. Expected waitingtime for appointments for urgent care, acute care, specialty care, and routineservices for prevention and wellness.
Thereport shall also include: the accessibility performance targets for theprevious and current years; data on actual overall accessibility as measured bydriving distance and average appointment waiting time; and an evaluation ofactual plan performance against performance targets. Measures of actualaccessibility may be developed using scientifically valid random sampletechniques.
d. A statement of thehealth benefit plan's methods and standards for determining whether in‑networkservices are reasonably available and accessible to a covered person, for thepurpose of determining whether a covered person should receive the in‑networklevel of coverage for services received from a nonnetwork provider.
e. A description of thehealth benefit plan's program to monitor the adequacy of its networkavailability and accessibility methodologies and performance targets, planperformance, and network provider performance.
f. A summary of thehealth benefit plan's utilization review program activities for the previouscalendar year. The report shall include the number of: each type of utilizationreview performed, noncertifications for each type of review, each type ofreview appealed, and appeals settled in favor of covered persons. The reportshall be accompanied by a certification from the carrier that it hasestablished and follows procedures that comply with G.S. 58‑50‑61.
(5) Aggregate financialcompensation data, including the percentage of providers paid under acapitation arrangement, discounted fee‑for‑service or salary, theservices included in the capitation payment, and the range of compensation paidby withhold or incentive payments. This information shall be submitted on aform prescribed by the Commissioner.
The name, or group orinstitutional name, of an individual provider may not be disclosed pursuant tothis subsection. No civil liability shall arise from compliance with theprovisions of this subsection, provided that the acts or omissions are made ingood faith and do not constitute gross negligence, willful or wantonmisconduct, or intentional wrongdoing.
(b) Disclosurerequirements. Each health benefit plan shall provide the following applicableinformation to plan participants and bona fide prospective participants uponrequest:
(1) The evidence ofcoverage (G.S. 58‑67‑50), subscriber contract (G.S. 58‑65‑60,58‑65‑140), health insurance policy (G.S. 58‑51‑80, 58‑50‑125,58‑50‑126, 58‑50‑55), or the contract and benefitsummary of any other type of health benefit plan;
(2) An explanation ofthe utilization review criteria and treatment protocol under which treatmentsare provided for conditions specified by the prospective participant. Thisexplanation shall be in writing if so requested;
(3) If denied arecommended treatment, written reasons for the denial and an explanation of theutilization review criteria or treatment protocol upon which the denial wasbased;
(4) The plan'sformularies, restricted access drugs or devices as defined in G.S. 58‑3‑221,or prior approval requirements for obtaining prescription drugs, whether aparticular drug or therapeutic class of drugs is excluded from its formulary,and the circumstances under which a nonformulary drug may be covered; and
(5) The plan'sprocedures and medically based criteria for determining whether a specifiedprocedure, test, or treatment is experimental.
(b1) Effective March 1,1998, insurers shall make the reports that are required under subsection (a) ofthis section and that have been filed with the Commissioner available on theirbusiness premises and shall provide any insured access to them upon request.
(c) For purposes ofthis section, "health benefit plan" or "plan" means (i)health maintenance organization (HMO) subscriber contracts and (ii) insurancecompany or hospital and medical service corporation preferred provider benefitplans as defined in G.S. 58‑50‑56. (1997‑480, s. 1; 1997‑519, s. 1.1; 2001‑334,s. 2.2; 2001‑446, s. 2.1; 2006‑154, s. 13; 2008‑124, s.10.1.)
§ 58‑3‑191. Managed care reporting and disclosure requirements.
(a) Each health benefitplan shall annually, on or before the first day of May of each year, file inthe office of the Commissioner the following information for the previouscalendar year:
(1) The number of andreasons for grievances received from plan participants regarding medicaltreatment. The report shall include the number of covered lives, total numberof grievances categorized by reason for the grievance, the number of grievancesreferred to the second level grievance review, the number of grievancesresolved at each level and their resolution, and a description of the actionsthat are being taken to correct the problems that have been identified throughgrievances received. Every health benefit plan shall file with theCommissioner, as part of its annual grievance report, a certificate ofcompliance stating that the carrier has established and follows, for each ofits lines of business, grievance procedures that comply with G.S. 58‑50‑62.
(2) The number ofparticipants and groups who terminated coverage under the plan for any reason.The report shall include the number of participants who terminated coveragebecause the group contract under which they were covered was terminated, the numberof participants who terminated coverage for reasons other than the terminationof the group under which they were enrolled, and the number of group contractsterminated.
(3) The number ofprovider contracts that were terminated and the reasons for termination. Thisinformation shall include the number of providers leaving the plan and thenumber of new providers. The report shall show voluntary and involuntaryterminations separately.
(4) Data relating to theutilization, quality, availability, and accessibility of services. The reportshall include the following:
a. Information on thehealth benefit plan's program to determine the level of network availability,as measured by the numbers and types of network providers, required to providecovered services to covered persons. This information shall include the plan'smethodology for:
1. Establishingperformance targets for the numbers and types of providers by specialty, areaof practice, or facility type, for each of the following categories: primary carephysicians, specialty care physicians, nonphysician health care providers,hospitals, and nonhospital health care facilities.
2. Determining whenchanges in plan membership will necessitate changes in the provider network.
Thereport shall also include: the availability performance targets for theprevious and current years; the numbers and types of providers currentlyparticipating in the health benefit plan's provider network; and an evaluationof actual plan performance against performance targets.
b. The health benefitplan's method for arranging or providing health care services from nonnetworkproviders, both within and outside of its service area, when network providersare not available to provide covered services.
c. Information on thehealth benefit plan's program to determine the level of provider networkaccessibility necessary to serve its membership. This information shall includethe health benefit plan's methodology for establishing performance targets formember access to covered services from primary care physicians, specialty carephysicians, nonphysician health care providers, hospitals, and nonhospitalhealth care facilities. The methodology shall establish targets for:
1. The proximity ofnetwork providers to members, as measured by member driving distance, to accessprimary care, specialty care, hospital‑based services, and services ofnonhospital facilities.
2. Expected waitingtime for appointments for urgent care, acute care, specialty care, and routineservices for prevention and wellness.
Thereport shall also include: the accessibility performance targets for theprevious and current years; data on actual overall accessibility as measured bydriving distance and average appointment waiting time; and an evaluation ofactual plan performance against performance targets. Measures of actualaccessibility may be developed using scientifically valid random sampletechniques.
d. A statement of thehealth benefit plan's methods and standards for determining whether in‑networkservices are reasonably available and accessible to a covered person, for thepurpose of determining whether a covered person should receive the in‑networklevel of coverage for services received from a nonnetwork provider.
e. A description of thehealth benefit plan's program to monitor the adequacy of its networkavailability and accessibility methodologies and performance targets, planperformance, and network provider performance.
f. A summary of thehealth benefit plan's utilization review program activities for the previouscalendar year. The report shall include the number of: each type of utilizationreview performed, noncertifications for each type of review, each type ofreview appealed, and appeals settled in favor of covered persons. The reportshall be accompanied by a certification from the carrier that it hasestablished and follows procedures that comply with G.S. 58‑50‑61.
(5) Aggregate financialcompensation data, including the percentage of providers paid under acapitation arrangement, discounted fee‑for‑service or salary, theservices included in the capitation payment, and the range of compensation paidby withhold or incentive payments. This information shall be submitted on aform prescribed by the Commissioner.
The name, or group orinstitutional name, of an individual provider may not be disclosed pursuant tothis subsection. No civil liability shall arise from compliance with theprovisions of this subsection, provided that the acts or omissions are made ingood faith and do not constitute gross negligence, willful or wantonmisconduct, or intentional wrongdoing.
(b) Disclosurerequirements. Each health benefit plan shall provide the following applicableinformation to plan participants and bona fide prospective participants uponrequest:
(1) The evidence ofcoverage (G.S. 58‑67‑50), subscriber contract (G.S. 58‑65‑60,58‑65‑140), health insurance policy (G.S. 58‑51‑80, 58‑50‑125,58‑50‑126, 58‑50‑55), or the contract and benefitsummary of any other type of health benefit plan;
(2) An explanation ofthe utilization review criteria and treatment protocol under which treatmentsare provided for conditions specified by the prospective participant. Thisexplanation shall be in writing if so requested;
(3) If denied arecommended treatment, written reasons for the denial and an explanation of theutilization review criteria or treatment protocol upon which the denial wasbased;
(4) The plan'sformularies, restricted access drugs or devices as defined in G.S. 58‑3‑221,or prior approval requirements for obtaining prescription drugs, whether aparticular drug or therapeutic class of drugs is excluded from its formulary,and the circumstances under which a nonformulary drug may be covered; and
(5) The plan'sprocedures and medically based criteria for determining whether a specifiedprocedure, test, or treatment is experimental.
(b1) Effective March 1,1998, insurers shall make the reports that are required under subsection (a) ofthis section and that have been filed with the Commissioner available on theirbusiness premises and shall provide any insured access to them upon request.
(c) For purposes ofthis section, "health benefit plan" or "plan" means (i)health maintenance organization (HMO) subscriber contracts and (ii) insurancecompany or hospital and medical service corporation preferred provider benefitplans as defined in G.S. 58‑50‑56. (1997‑480, s. 1; 1997‑519, s. 1.1; 2001‑334,s. 2.2; 2001‑446, s. 2.1; 2006‑154, s. 13; 2008‑124, s.10.1.)
