§ 58‑3‑227. (SeeEditor's note for effective date and applicability) Health plans fee schedules.
(a) Definitions. Asused in this section, the following terms mean:
(1) Claim submissionpolicy. The procedure adopted by an insurer and used by a provider orfacility to submit to the insurer claims for services rendered and to seekreimbursement for those services.
(2) Health care facilityor facility. A facility that is licensed under Chapter 131E or Chapter 122Cof the General Statutes or is owned or operated by the State of North Carolinain which health care services are provided to patients.
(3) Health care provideror provider. An individual who is licensed, certified, or otherwiseauthorized under Chapter 90 or Chapter 90B of the General Statutes or under thelaws of another state to provide health care services in the ordinary course ofbusiness or practice of a profession or in an approved education or trainingprogram.
(4) Insurer. An entitythat writes a health benefit plan and that is an insurance company subject tothis Chapter, a service corporation under Article 65 of this Chapter, a healthmaintenance organization under Article 67 of this Chapter, or a multipleemployer welfare arrangement under Article 49 of this Chapter, except it doesnot include an entity that writes stand alone dental insurance.
(5) Reimbursementpolicy. Information relating to payment of providers and facilities includingpolicies on the following:
a. Claims bundling andother claims editing processes.
b. Recognition ornonrecognition of CPT code modifiers.
c. Downcoding ofservices or procedures.
d. The definition ofglobal surgery periods.
e. Multiple surgicalprocedures.
f. Payment based onthe relationship of procedure code to diagnosis code.
(6) Schedule of fees. CPT, HCPCS, ICD‑9‑ CM codes, ASA codes, modifiers, and otherapplicable codes for the procedures billed for that class of provider.
(b) Purpose. Thepurpose of this section is to establish the minimum required provisions for thedisclosure and notification of an insurer's schedule of fees, claimssubmission, and reimbursement policies to health care providers and health carefacilities. Nothing in this section shall supercede (i) the schedule of fees,claim submission, and reimbursement policy terms in an insurer's contract witha provider or facility that exceed the minimum requirements of this section nor(ii) any contractual requirement for mutual written consent of changes toreimbursement policies, claims submission policies, or fees. Nothing in thissection shall prevent an insurer from requiring that providers and facilitieskeep confidential, and not disclose to third parties, the information that aninsurer must provide under this section.
(c) (See Editor'snote) Disclosure of Fee Schedules. An insurer shall make available tocontracted providers the following information:
(1) The insurer'sschedule of fees associated with the top 30 services or procedures mostcommonly billed by that class of provider, and, upon request, the full scheduleof fees for services or procedures billed by that class of provider, inaccordance with subdivision (3) of this subsection.
(2) In the case of acontract incorporating multiple classes of providers, the insurer's schedule offees associated with the top 30 services or procedures most commonly billed foreach class of provider, and, upon request, the full schedule of fees forservices or procedures billed for each class of provider, in accordance withsubdivision (3) of this subsection.
(3) If a provider requestsfees for more than 30 services and procedures, the insurer may require theprovider to specify the additional requested services and procedures and maylimit the provider's access to the additional schedule of fees to thoseassociated with services and procedures performed by or reasonably expected tobe performed by the provider. The insurer may also limit the frequency ofrequests for the additional codes by each provider, provided that suchadditional codes will be made available upon request at least annually and atany time there are changes for which notification is required pursuant tosubsection (f) of this section.
(d) Disclosure ofPolicies. An insurer shall make available to contracted providers andfacilities a description of the insurer's claim submission and reimbursementpolicies.
(e) Availability ofInformation. Insurers shall notify contracted providers and facilities inwriting of the availability of information required or authorized to beprovided under this section. An insurer may satisfy this requirement byindicating in the contract with the provider the availability of thisinformation or by providing notice in a manner authorized under subsection (f)of this section for notification of changes.
(f) Notification ofChanges. Insurers shall provide advance notice to providers and facilities ofchanges to the information that insurers are required to provide under thissection. The notice period for a change in the schedule of fees, reimbursementpolicies, or submission of claims policies shall be the contractual noticeperiod, but in no event shall the notices be given less than 30 days prior tothe change. An insurer is not required to provide advance notice of changes tothe information required under this section if the change has the effect ofincreasing fees, expanding health benefit plan coverage, or is made for patientsafety considerations, in which case, notification of the changes may be madeconcurrent with the implementation of the changes. Information and notice of changesmay be provided in the medium selected by the insurer, including an electronicmedium. However, the insurer must inform the affected contracted provider orfacility of the notification method to be used by the insurer and, if theinsurer uses an electronic medium to provide notice of changes required underthis section, the insurer shall provide clear instructions regarding how theprovider or facility may access the information contained in the notice.
(g) ReferenceInformation. If an insurer references source information that is the basisfor a schedule of fees, reimbursement policy, or claim submission policy, andthe source information is developed independently of the insurer, the insurermay satisfy the requirements of this section by providing clear instructionsregarding how the provider or facility may readily access the sourceinformation or by providing for actual access if agreed to in the contractbetween the insurer and the provider.
(h) ContractNegotiations. When an insurer offers a contract to a provider, the insurershall also make available its schedule of fees associated with the top 30services or procedures most commonly billed by that class of provider. Upon therequest of a provider, the insurer shall also make available the full scheduleof fees for services or procedures billed by that class of provider or for eachclass of provider in the case of a contract incorporating multiple classes ofproviders. If a provider requests fees for more than 30 services andprocedures, the insurer may require the provider to specify the additionalrequested services and procedures and may limit the provider's access to theadditional schedule of fees to those associated with services and proceduresperformed by or reasonably expected to be performed by the provider.
(i) (See Editor'snote) Exemptions. Except for the information required to be providedunder subsection (c) of this section, this section does not apply to:
(1) Claims processed byan insurer on a claims adjudication system that was implemented prior toJanuary 1, 1982, provided that the insurer (i) verifies with the Commissionerthat its claims adjudication system qualified under this subsection, (ii) isimplementing a new claims adjudication software system, and (iii) is proceedingin good faith to move all insured claims to the new system as soon as possibleand in any event no later than December 31, 2004; or
(2) Information that theinsurer verifies with the Commissioner is required to be provided by the termsof a national settlement agreement between the insurer and trade associationsrepresenting certain providers, provided that the agreement is approved priorto March 1, 2004, by the court having jurisdiction over the settlement. Theexemption provided in this subdivision shall be limited to those terms of theagreement that are required to be implemented no later than December 31, 2004.Nothing in this subdivision shall be construed to relieve the insurer ofcomplying with any terms and deadlines as set out in the agreement. (2003‑369, s. 1.)
§ 58‑3‑227. (SeeEditor's note for effective date and applicability) Health plans fee schedules.
(a) Definitions. Asused in this section, the following terms mean:
(1) Claim submissionpolicy. The procedure adopted by an insurer and used by a provider orfacility to submit to the insurer claims for services rendered and to seekreimbursement for those services.
(2) Health care facilityor facility. A facility that is licensed under Chapter 131E or Chapter 122Cof the General Statutes or is owned or operated by the State of North Carolinain which health care services are provided to patients.
(3) Health care provideror provider. An individual who is licensed, certified, or otherwiseauthorized under Chapter 90 or Chapter 90B of the General Statutes or under thelaws of another state to provide health care services in the ordinary course ofbusiness or practice of a profession or in an approved education or trainingprogram.
(4) Insurer. An entitythat writes a health benefit plan and that is an insurance company subject tothis Chapter, a service corporation under Article 65 of this Chapter, a healthmaintenance organization under Article 67 of this Chapter, or a multipleemployer welfare arrangement under Article 49 of this Chapter, except it doesnot include an entity that writes stand alone dental insurance.
(5) Reimbursementpolicy. Information relating to payment of providers and facilities includingpolicies on the following:
a. Claims bundling andother claims editing processes.
b. Recognition ornonrecognition of CPT code modifiers.
c. Downcoding ofservices or procedures.
d. The definition ofglobal surgery periods.
e. Multiple surgicalprocedures.
f. Payment based onthe relationship of procedure code to diagnosis code.
(6) Schedule of fees. CPT, HCPCS, ICD‑9‑ CM codes, ASA codes, modifiers, and otherapplicable codes for the procedures billed for that class of provider.
(b) Purpose. Thepurpose of this section is to establish the minimum required provisions for thedisclosure and notification of an insurer's schedule of fees, claimssubmission, and reimbursement policies to health care providers and health carefacilities. Nothing in this section shall supercede (i) the schedule of fees,claim submission, and reimbursement policy terms in an insurer's contract witha provider or facility that exceed the minimum requirements of this section nor(ii) any contractual requirement for mutual written consent of changes toreimbursement policies, claims submission policies, or fees. Nothing in thissection shall prevent an insurer from requiring that providers and facilitieskeep confidential, and not disclose to third parties, the information that aninsurer must provide under this section.
(c) (See Editor'snote) Disclosure of Fee Schedules. An insurer shall make available tocontracted providers the following information:
(1) The insurer'sschedule of fees associated with the top 30 services or procedures mostcommonly billed by that class of provider, and, upon request, the full scheduleof fees for services or procedures billed by that class of provider, inaccordance with subdivision (3) of this subsection.
(2) In the case of acontract incorporating multiple classes of providers, the insurer's schedule offees associated with the top 30 services or procedures most commonly billed foreach class of provider, and, upon request, the full schedule of fees forservices or procedures billed for each class of provider, in accordance withsubdivision (3) of this subsection.
(3) If a provider requestsfees for more than 30 services and procedures, the insurer may require theprovider to specify the additional requested services and procedures and maylimit the provider's access to the additional schedule of fees to thoseassociated with services and procedures performed by or reasonably expected tobe performed by the provider. The insurer may also limit the frequency ofrequests for the additional codes by each provider, provided that suchadditional codes will be made available upon request at least annually and atany time there are changes for which notification is required pursuant tosubsection (f) of this section.
(d) Disclosure ofPolicies. An insurer shall make available to contracted providers andfacilities a description of the insurer's claim submission and reimbursementpolicies.
(e) Availability ofInformation. Insurers shall notify contracted providers and facilities inwriting of the availability of information required or authorized to beprovided under this section. An insurer may satisfy this requirement byindicating in the contract with the provider the availability of thisinformation or by providing notice in a manner authorized under subsection (f)of this section for notification of changes.
(f) Notification ofChanges. Insurers shall provide advance notice to providers and facilities ofchanges to the information that insurers are required to provide under thissection. The notice period for a change in the schedule of fees, reimbursementpolicies, or submission of claims policies shall be the contractual noticeperiod, but in no event shall the notices be given less than 30 days prior tothe change. An insurer is not required to provide advance notice of changes tothe information required under this section if the change has the effect ofincreasing fees, expanding health benefit plan coverage, or is made for patientsafety considerations, in which case, notification of the changes may be madeconcurrent with the implementation of the changes. Information and notice of changesmay be provided in the medium selected by the insurer, including an electronicmedium. However, the insurer must inform the affected contracted provider orfacility of the notification method to be used by the insurer and, if theinsurer uses an electronic medium to provide notice of changes required underthis section, the insurer shall provide clear instructions regarding how theprovider or facility may access the information contained in the notice.
(g) ReferenceInformation. If an insurer references source information that is the basisfor a schedule of fees, reimbursement policy, or claim submission policy, andthe source information is developed independently of the insurer, the insurermay satisfy the requirements of this section by providing clear instructionsregarding how the provider or facility may readily access the sourceinformation or by providing for actual access if agreed to in the contractbetween the insurer and the provider.
(h) ContractNegotiations. When an insurer offers a contract to a provider, the insurershall also make available its schedule of fees associated with the top 30services or procedures most commonly billed by that class of provider. Upon therequest of a provider, the insurer shall also make available the full scheduleof fees for services or procedures billed by that class of provider or for eachclass of provider in the case of a contract incorporating multiple classes ofproviders. If a provider requests fees for more than 30 services andprocedures, the insurer may require the provider to specify the additionalrequested services and procedures and may limit the provider's access to theadditional schedule of fees to those associated with services and proceduresperformed by or reasonably expected to be performed by the provider.
(i) (See Editor'snote) Exemptions. Except for the information required to be providedunder subsection (c) of this section, this section does not apply to:
(1) Claims processed byan insurer on a claims adjudication system that was implemented prior toJanuary 1, 1982, provided that the insurer (i) verifies with the Commissionerthat its claims adjudication system qualified under this subsection, (ii) isimplementing a new claims adjudication software system, and (iii) is proceedingin good faith to move all insured claims to the new system as soon as possibleand in any event no later than December 31, 2004; or
(2) Information that theinsurer verifies with the Commissioner is required to be provided by the termsof a national settlement agreement between the insurer and trade associationsrepresenting certain providers, provided that the agreement is approved priorto March 1, 2004, by the court having jurisdiction over the settlement. Theexemption provided in this subdivision shall be limited to those terms of theagreement that are required to be implemented no later than December 31, 2004.Nothing in this subdivision shall be construed to relieve the insurer ofcomplying with any terms and deadlines as set out in the agreement. (2003‑369, s. 1.)
§ 58‑3‑227. (SeeEditor's note for effective date and applicability) Health plans fee schedules.
(a) Definitions. Asused in this section, the following terms mean:
(1) Claim submissionpolicy. The procedure adopted by an insurer and used by a provider orfacility to submit to the insurer claims for services rendered and to seekreimbursement for those services.
(2) Health care facilityor facility. A facility that is licensed under Chapter 131E or Chapter 122Cof the General Statutes or is owned or operated by the State of North Carolinain which health care services are provided to patients.
(3) Health care provideror provider. An individual who is licensed, certified, or otherwiseauthorized under Chapter 90 or Chapter 90B of the General Statutes or under thelaws of another state to provide health care services in the ordinary course ofbusiness or practice of a profession or in an approved education or trainingprogram.
(4) Insurer. An entitythat writes a health benefit plan and that is an insurance company subject tothis Chapter, a service corporation under Article 65 of this Chapter, a healthmaintenance organization under Article 67 of this Chapter, or a multipleemployer welfare arrangement under Article 49 of this Chapter, except it doesnot include an entity that writes stand alone dental insurance.
(5) Reimbursementpolicy. Information relating to payment of providers and facilities includingpolicies on the following:
a. Claims bundling andother claims editing processes.
b. Recognition ornonrecognition of CPT code modifiers.
c. Downcoding ofservices or procedures.
d. The definition ofglobal surgery periods.
e. Multiple surgicalprocedures.
f. Payment based onthe relationship of procedure code to diagnosis code.
(6) Schedule of fees. CPT, HCPCS, ICD‑9‑ CM codes, ASA codes, modifiers, and otherapplicable codes for the procedures billed for that class of provider.
(b) Purpose. Thepurpose of this section is to establish the minimum required provisions for thedisclosure and notification of an insurer's schedule of fees, claimssubmission, and reimbursement policies to health care providers and health carefacilities. Nothing in this section shall supercede (i) the schedule of fees,claim submission, and reimbursement policy terms in an insurer's contract witha provider or facility that exceed the minimum requirements of this section nor(ii) any contractual requirement for mutual written consent of changes toreimbursement policies, claims submission policies, or fees. Nothing in thissection shall prevent an insurer from requiring that providers and facilitieskeep confidential, and not disclose to third parties, the information that aninsurer must provide under this section.
(c) (See Editor'snote) Disclosure of Fee Schedules. An insurer shall make available tocontracted providers the following information:
(1) The insurer'sschedule of fees associated with the top 30 services or procedures mostcommonly billed by that class of provider, and, upon request, the full scheduleof fees for services or procedures billed by that class of provider, inaccordance with subdivision (3) of this subsection.
(2) In the case of acontract incorporating multiple classes of providers, the insurer's schedule offees associated with the top 30 services or procedures most commonly billed foreach class of provider, and, upon request, the full schedule of fees forservices or procedures billed for each class of provider, in accordance withsubdivision (3) of this subsection.
(3) If a provider requestsfees for more than 30 services and procedures, the insurer may require theprovider to specify the additional requested services and procedures and maylimit the provider's access to the additional schedule of fees to thoseassociated with services and procedures performed by or reasonably expected tobe performed by the provider. The insurer may also limit the frequency ofrequests for the additional codes by each provider, provided that suchadditional codes will be made available upon request at least annually and atany time there are changes for which notification is required pursuant tosubsection (f) of this section.
(d) Disclosure ofPolicies. An insurer shall make available to contracted providers andfacilities a description of the insurer's claim submission and reimbursementpolicies.
(e) Availability ofInformation. Insurers shall notify contracted providers and facilities inwriting of the availability of information required or authorized to beprovided under this section. An insurer may satisfy this requirement byindicating in the contract with the provider the availability of thisinformation or by providing notice in a manner authorized under subsection (f)of this section for notification of changes.
(f) Notification ofChanges. Insurers shall provide advance notice to providers and facilities ofchanges to the information that insurers are required to provide under thissection. The notice period for a change in the schedule of fees, reimbursementpolicies, or submission of claims policies shall be the contractual noticeperiod, but in no event shall the notices be given less than 30 days prior tothe change. An insurer is not required to provide advance notice of changes tothe information required under this section if the change has the effect ofincreasing fees, expanding health benefit plan coverage, or is made for patientsafety considerations, in which case, notification of the changes may be madeconcurrent with the implementation of the changes. Information and notice of changesmay be provided in the medium selected by the insurer, including an electronicmedium. However, the insurer must inform the affected contracted provider orfacility of the notification method to be used by the insurer and, if theinsurer uses an electronic medium to provide notice of changes required underthis section, the insurer shall provide clear instructions regarding how theprovider or facility may access the information contained in the notice.
(g) ReferenceInformation. If an insurer references source information that is the basisfor a schedule of fees, reimbursement policy, or claim submission policy, andthe source information is developed independently of the insurer, the insurermay satisfy the requirements of this section by providing clear instructionsregarding how the provider or facility may readily access the sourceinformation or by providing for actual access if agreed to in the contractbetween the insurer and the provider.
(h) ContractNegotiations. When an insurer offers a contract to a provider, the insurershall also make available its schedule of fees associated with the top 30services or procedures most commonly billed by that class of provider. Upon therequest of a provider, the insurer shall also make available the full scheduleof fees for services or procedures billed by that class of provider or for eachclass of provider in the case of a contract incorporating multiple classes ofproviders. If a provider requests fees for more than 30 services andprocedures, the insurer may require the provider to specify the additionalrequested services and procedures and may limit the provider's access to theadditional schedule of fees to those associated with services and proceduresperformed by or reasonably expected to be performed by the provider.
(i) (See Editor'snote) Exemptions. Except for the information required to be providedunder subsection (c) of this section, this section does not apply to:
(1) Claims processed byan insurer on a claims adjudication system that was implemented prior toJanuary 1, 1982, provided that the insurer (i) verifies with the Commissionerthat its claims adjudication system qualified under this subsection, (ii) isimplementing a new claims adjudication software system, and (iii) is proceedingin good faith to move all insured claims to the new system as soon as possibleand in any event no later than December 31, 2004; or
(2) Information that theinsurer verifies with the Commissioner is required to be provided by the termsof a national settlement agreement between the insurer and trade associationsrepresenting certain providers, provided that the agreement is approved priorto March 1, 2004, by the court having jurisdiction over the settlement. Theexemption provided in this subdivision shall be limited to those terms of theagreement that are required to be implemented no later than December 31, 2004.Nothing in this subdivision shall be construed to relieve the insurer ofcomplying with any terms and deadlines as set out in the agreement. (2003‑369, s. 1.)
