56-60-107. Requirements for granting a third party access to the contracting entity's provider network Refusal to accept contractual discount. [Effective January 1, 2010.]
(a) No contracting entity shall grant a third party access to the contracting entity's provider network contract by lease, rent or by any other means unless the third party accessing the provider network contract is:
(1) A payer of claims or a third party administrator or other entity that administers or processes claims on behalf of the payer;
(2) A preferred provider organization or preferred provider network including a physician organization or physician-hospital organization; or
(3) An entity engaged in the electronic claims transport between the contracting entity and the payer if the entity does not provide access to the provider's services and contractual discounts to any other third party.
(b) (1) A provider may refuse the discount taken on the remittance advice (RA) or explanation of payment (EOP) if the discount is taken without a contractual basis or if the provider cannot obtain information relative to the discount because of a violation of § 56-60-105(b)(2) or § 56-60-106(c). The provider shall notify in writing the contracting entity or third party of the provider's refusal to accept the contractual discount.
(2) The provider may require payment of the charge with no discount applied unless the contracting entity or third party within thirty (30) calendar days of receipt of notice of the apparent violation of the requirements of this section:
(A) Notifies the provider that the apparent violation resulted from an administrative oversight or other unintentional error and advises the provider of steps taken to remedy and avoid recurrence of the error; and
(B) Submits to the provider a corrected RA or EOP with documentation demonstrating eligibility for any discount applied.
56-60-107. Requirements for granting a third party access to the contracting entity's provider network Refusal to accept contractual discount. [Effective January 1, 2010.]
(a) No contracting entity shall grant a third party access to the contracting entity's provider network contract by lease, rent or by any other means unless the third party accessing the provider network contract is:
(1) A payer of claims or a third party administrator or other entity that administers or processes claims on behalf of the payer;
(2) A preferred provider organization or preferred provider network including a physician organization or physician-hospital organization; or
(3) An entity engaged in the electronic claims transport between the contracting entity and the payer if the entity does not provide access to the provider's services and contractual discounts to any other third party.
(b) (1) A provider may refuse the discount taken on the remittance advice (RA) or explanation of payment (EOP) if the discount is taken without a contractual basis or if the provider cannot obtain information relative to the discount because of a violation of § 56-60-105(b)(2) or § 56-60-106(c). The provider shall notify in writing the contracting entity or third party of the provider's refusal to accept the contractual discount.
(2) The provider may require payment of the charge with no discount applied unless the contracting entity or third party within thirty (30) calendar days of receipt of notice of the apparent violation of the requirements of this section:
(A) Notifies the provider that the apparent violation resulted from an administrative oversight or other unintentional error and advises the provider of steps taken to remedy and avoid recurrence of the error; and
(B) Submits to the provider a corrected RA or EOP with documentation demonstrating eligibility for any discount applied.
56-60-107. Requirements for granting a third party access to the contracting entity's provider network Refusal to accept contractual discount. [Effective January 1, 2010.]
(a) No contracting entity shall grant a third party access to the contracting entity's provider network contract by lease, rent or by any other means unless the third party accessing the provider network contract is:
(1) A payer of claims or a third party administrator or other entity that administers or processes claims on behalf of the payer;
(2) A preferred provider organization or preferred provider network including a physician organization or physician-hospital organization; or
(3) An entity engaged in the electronic claims transport between the contracting entity and the payer if the entity does not provide access to the provider's services and contractual discounts to any other third party.
(b) (1) A provider may refuse the discount taken on the remittance advice (RA) or explanation of payment (EOP) if the discount is taken without a contractual basis or if the provider cannot obtain information relative to the discount because of a violation of § 56-60-105(b)(2) or § 56-60-106(c). The provider shall notify in writing the contracting entity or third party of the provider's refusal to accept the contractual discount.
(2) The provider may require payment of the charge with no discount applied unless the contracting entity or third party within thirty (30) calendar days of receipt of notice of the apparent violation of the requirements of this section:
(A) Notifies the provider that the apparent violation resulted from an administrative oversight or other unintentional error and advises the provider of steps taken to remedy and avoid recurrence of the error; and
(B) Submits to the provider a corrected RA or EOP with documentation demonstrating eligibility for any discount applied.
