- House Committee Substitute -

HCS/SB 856 - This act makes a technical drafting change. Clarifies that a managed care organization is to be certified by the Department of Insurance rather than the Department of Health. This act clarifies that Section 354.603, RSMo, does not require

providers to submit copies of their income tax returns to a

health carrier. The entity may require a provider to obtain

audited financial statements if the provider receives 10% or

more of the total medical expenditures made by the health

carrier.

This act specifies that the "prompt pay" provisions of Section 376.383 apply after a health carrier receives a claim for a health care service. The current statute applies when a carrier receives a claim from a person entitled to reimbursement. The carrier is also required to provide, within 45 days of receiving the claim, a complete description of all additional information that is necessary to process the entire claim.

This act allows a person who has filed a claim for reimbursement for a health care service to file a civil action against a carrier for violations of the "prompt pay" provisions of Section 376.383. The court may award attorney fees and costs to a prevailing plaintiff unless the court finds that the carrier's position was substantially justified.

This act requires health carriers, when processing claims, to permit providers to file confirmation numbers of authorized services and claims for reimbursement in the same format, to allow providers to file claims for reimbursement for a period of at least one year following the provision of a health care service, to issue within 24 hours an electronic confirmation of receiving a claim for reimbursement, and to accept all medical codes and modifiers used by the Health Care Financing Administration.

This act requires health carriers to furnish providers with a current fee schedule for reimbursement amounts of covered services. This act also prohibits carriers from requesting a refund against a claim more than 6 months after the provider has filed the claim except in cases of fraud or misrepresentation by the provider. This act requires health carriers to provide Internet access to a current provider directory.

This act requires health carriers to inform enrollees of any denial of health care coverage. The explanation must be in plain

language that is easy for a layperson to understand.

This act requires health carriers to provide, upon proper notification, an enrollee with the forms and instructions necessary to enroll a newly born child if an application is required in order to continue coverage beyond the thirty-one day period after the child's birth. The health carrier shall allow the enrollee an additional 31 days from the date the forms are provided in which to enroll the newly born child.

This act prohibits "hold harmless" clauses that require a health care provider to assume the sole liability of the provision of health care services. This act prohibits health carriers from requiring a health care provider to agree to participate in all health care plans operated by the health carrier as a condition for participating in one plan. This act also prohibits health carriers from requiring health care providers to participate in lease business if the health carrier leases its provider network to another health carrier without the provider's consent.

This act requires group insurers to issue to enrollees a card that includes a telephone number for the plan and a brief description of the enrollee's type of health care plan.

This act requires insurers to provide both parents of a covered child with coverage information regardless of whether the parent is the primary policyholder.

This act requires health carriers to notify the pharmacist, primary care physician, and enrollee when a nonformulary drug is authorized for a limited period of time or when the health carrier modifies its formulary in a manner that affects the authorization or coverage of a drug that was previously authorized or covered before such modification.

This act allows a health carrier to retract a prior authorization of a health care service if the enrollee's coverage under the plan has exceeded the enrollee's lifetime or annual benefits limit. Certification of a health care service is deemed to be an authorization of a health care service.

This act requires health carriers to use, after January 1, 2002, standardized forms for referrals and the explanation of benefits. The Department of Insurance must establish a task force to develop the standardized forms.

This act requires all managed care organizations to allow enrolles the right to select long-term care facilities which have the same religious orientation as demonstrated by the enrollee. If a religiously appropriate facility is not within the managed care organization's provider network, it shall provide the enrollee the option to receive care from an out-of-network long-term-care facility. In order to receive care from an out-of-network long-term-care facility, the facility must be willing to provide its services to the resident; the facility and its health care professionals must meet all licensing and training standards prescribed by law; the facility must be certified through Medicare; and the facility must agree to abide by the terms and conditions of the managed care organization's contract with similar providers. The managed care organization shall reimburse the facility at a rate not less than the Medicare allowable rate pursuant to Medicare rules and regulations.

This act is similar to HB 1932 (2000).

STEPHEN WITTE