Section 3.26.110. Additional standards for prompt, fair, and equitable settlements of health claims.

	(a)  A person that provides coverage in this state for health care services or supplies on an expense incurred basis for which benefits are based on an amount that is less than the actual amount billed for the health care services or supplies shall  
		(1) maintain or use a statistically credible profile of covered health care services and supplies on which to base payment; the profile must  
			(A) be updated at least every six months;  
			(B) contain billed charges for services performed not more than one year before the date of the most recent profile; and  
			(C) contain billed charges for each geographical area in which a claimant might receive treatment or, if statistically credible data for a particular service or supply item in a certain geographical area is unavailable, contain a sufficient number of billed charges for that service or supply item from another geographical area so that a reliable basis is established;  
		(2) except as provided in (3) of this subsection, determine the final payment for a covered service or supply based on an amount that  
			(A) reflects the general cost differences between the geographical area where the service was performed and the other geographical areas used in establishing the statistically credible profile under (1) of this subsection; and   
			(B) is equal to or greater than the 80th percentile of charges under (1) of this subsection for the health care services or supplies;  
		(3) for a vaccine covered by an insurance policy that is an included vaccine and purchased by a provider instead of obtained from the state under the statewide immunization program established under AS 18.09.200, determine the final payment for the covered vaccine at an amount equal to or greater than the cost of the state purchased vaccine under the statewide immunization program; in this paragraph, "included vaccine" has the meaning given in AS 18.09.990;  
		(4) provide with any claim payment an explanation of the basis of payments in clear and simple terms, including explanation of any adjustments made under (2)(A) of this subsection, and document the explanation provided in the claim file; and  
		(5) provide an explanation in the health insurance policy of the basis of payments, including any payments for which a covered individual may be responsible and include on any schedule or summary of benefits page accompanying the policy  
			(A) the percentile used to determine final payment under (2)(B) of this subsection; and  
			(B) a statement regarding whether the covered individual is responsible for any amount billed for a health care service or supply item that exceeds the amount of final payment.  
	(b)  This section does not apply to workers' compensation claims.  
	(c)  If a person who is required to include a coordination of benefits provision under AS 21.42.205 provides coverage on a secondary basis,  
		(1) absent evidence of fraud, the secondary insurer must accept the primary insurer's precertification, utilization review, or other managed care requirement determination and may not deny, delay, or reduce benefits under its policy for a covered person who has met the primary insurer's precertification, utilization review, or other managed care requirement; and  
		(2) the secondary insurer must calculate its covered benefits at no greater cost to the covered person than if the health care services were obtained from the secondary insurer's participating provider if  
			(A) the secondary policy provides benefits through a provider network but the primary insurer's policy does not provide coverage through a provider network;  
			(B) both the primary policy and the secondary policy provide benefits through provider networks but the covered person obtains health care services from a provider that is in the provider network of the primary insurer but not the provider network of the secondary insurer; or  
			(C) both the primary policy and the secondary policy provide benefits through provider networks but the covered person obtains health care services from a provider that is not part of the provider network of the primary insurer or the secondary insurer because no provider in the primary insurer's provider network is able to meet the particular health need of the covered person.  
	(d)  A health care insurer shall give written notice to a health care provider, health care facility, or consumer at least 30 calendar days before the insurer seeks recovery of an overpayment. The notice must include adequate information for the health care provider, health care facility, or consumer to identify the specific claim and the specific reason for the recovery. A health care insurer may not initiate recovery of an overpayment more than 365 days after the date the original payment was made to a health care provider, health care facility, or consumer, or its agents, unless the health care insurer has clear and documented reason to believe that the health care provider, the health care facility, or consumer, or its agents has committed fraud or other intentional misconduct.   
	(e)  A health care insurer shall provide a health care provider, health care facility, or consumer with an opportunity to challenge the recovery of an overpayment, including sharing of claims information, and shall establish written policies and procedures for a health care provider, health care facility, or consumer to follow in order to challenge the recovery of an overpayment.   
	(f)  If a health insurance policy provides in-network and out-of-network benefits, the policy must provide at a minimum the in-network benefit level for the following:  
		(1) emergency services;  
		(2) services or supplies provided by an out-of-network health care provider or health care facility, if an in-network health care provider or health care facility is not reasonably accessible as defined in the policy;  
		(3) services provided by an out-of-network health care provider as part of a covered stay at an in-network health care facility when a covered individual does not have or is not given a choice of health care provider.  
	(g)  An insurer may require a covered individual to purchase specialty drugs from a specific in-network health care provider in order to receive benefits under a health insurance policy, unless the specialty drug is not available from the health care provider when needed and a delay in receiving the drug would threaten the efficacy of treatment or the life of the covered individual.  
	(h)  An insurer may require a covered individual to receive transplant services from an in-network health care provider in order to receive benefits under a health insurance policy, unless transplant services are not available from a network health care provider when needed and a delay in receiving the transplant services would threaten the efficacy of treatment or the life of the covered individual.  
	(i)  An insurer may not process claims based on a procedure code that differs from the procedure code specified in the claim unless agreed upon by the health care provider that provided the service or supply.  
	(j)  If an insurer provides benefits to a domestic partner, then the insurer may not unfairly discriminate on the basis of gender and must provide benefits to both same and opposite gender domestic partners.  
	(k)  If an insurer, for purposes of negotiating discounts with a health care provider, delays payment of an otherwise clean claim beyond the timeframes under AS 21.36.495, the insurer is subject to the 15 percent interest penalty under AS 21.36.495(c) or (d).  
	(l)  An insurer may not reduce the payment on a current claim for an overpayment on a previous claim unless the reduction  
		(1) is determined to be in compliance with (d) and (e) of this section; and  
		(2) does not result in a reduction on the amount allowed on any other claims of the covered individual.  

Authorities

21.06.090;21.36.125;21.36.495;21.42.205;01.05.031;21.36.350;44.62.125

Notes

Authority

AS 21.06.090 AS 21.36.125 AS 21.36.495 AS 21.42.205 Editor's note: In 2010 the revisor of statutes, acting under AS 01.05.031, redesignated former AS 21.36.350 as AS 21.36.125(c). As of Register 196 (January 2011), the regulations attorney made a conforming technical revision under AS 44.62.125(b)(6), to the authority citation that follows 3 AAC 26.110, deleting the citation to former AS 21.36.350 to reflect that the authority citation already includes a citation to AS 21.36.125, the section where material formerly in AS 21.36.350 was relocated.

History

Eff. 5/6/89, Register 110; am 4/20/97, Register 142; am 1/2/98, Register 145; am 9/15/2004, Register 171; am 10/16/2011, Register 200; am 12/16/2015, Register 216; am 8/20/2016, Register 219

References

3.26.110