State Codes and Statutes
Statutes > Vermont > Title-18 > Chapter-221 > 9418b
§ 9418b. Prior authorization
(a) Health plans shall pay claims for health care services for which prior authorization was required by and received from the health plan, unless:
(1) The insured was not a covered individual at the time the service was rendered;
(2) The insured's benefit limitations were exhausted;
(3) The prior authorization was based on materially inaccurate information from the health care provider;
(4) The health plan has a reasonable belief that fraud or other intentional misconduct has occurred; or
(5) The health plan determines through coordination of benefits that another health insurer is liable for the claim.
(b) Notwithstanding the provisions of subsection (a) of this section, nothing in this section shall be construed to prohibit a health plan from denying continued or extended coverage as part of concurrent review, denying a claim if the health plan is not primarily obligated to pay the claim, or applying payment policies that are consistent with an applicable law, rule, or regulation.
(c) A health plan shall furnish, upon request from a health care provider, a current list of services and supplies requiring prior authorization.
(d) A health plan shall post a current list of services and supplies requiring prior authorization to the insurer's website.
(e) In addition to any other remedy provided by law, if the commissioner finds that a health plan has engaged in a pattern and practice of violating this section, the commissioner may impose an administrative penalty against the health plan of no more than $500.00 for each violation, and may order the health plan to cease and desist from further violations and order the health plan to remediate the violation. In determining the amount of penalty to be assessed, the commissioner shall consider the following factors:
(1) The appropriateness of the penalty with respect to the financial resources and good faith of the health plan.
(2) The gravity of the violation or practice.
(3) The history of previous violations or practices of a similar nature.
(4) The economic benefit derived by the health plan and the economic impact on the health care facility or health care provider resulting from the violation.
(5) Any other relevant factors.
(f) Nothing in this section shall be construed to prohibit a health plan from applying payment policies that are consistent with applicable federal or state laws and regulations, or to relieve a health plan from complying with payment standards established by federal or state laws and regulations, including rules adopted by the commissioner pursuant to section 9408 of this title, relating to claims administration and adjudication standards, and rules adopted by the commissioner pursuant to section 9414 of this title and section 4088f of Title 8, relating to pay for performance or other payment methodology standards. (Added 2007, No. 203 (Adj. Sess.), § 29, eff. June 10, 2008; amended 2009, No. 61, § 31.)
