§ 58-50-30. Right to choose services of optometrist, podiatrist, licensed clinical social worker, certified substance abuse professional, licensed professional counselor, dentist, chiropractor, psycho
§ 58‑50‑30. Rightto choose services of optometrist, podiatrist, licensed clinical social worker,certified substance abuse professional, licensed professional counselor,dentist, chiropractor, psychologist, pharmacist, certified fee‑basedpracticing pastoral counselor, advanced practice nurse, licensed marriage andfamily therapist, or physician assistant.
(a) Repealed by SessionLaws 2001‑297, s. 1, effective January 1, 2001.
(a1) Whenever any healthbenefit plan, subscriber contract, or policy of insurance issued by a healthmaintenance organization, hospital or medical service corporation, or insurergoverned by Articles 1 through 67 of this Chapter provides for coverage for,payment of, or reimbursement for any service rendered in connection with a conditionor complaint that is within the scope of practice of a duly licensedoptometrist, a duly licensed podiatrist, a duly licensed dentist, a dulylicensed chiropractor, a duly licensed clinical social worker, a duly certifiedsubstance abuse professional, a duly licensed professional counselor, a dulylicensed psychologist, a duly licensed pharmacist, a duly certified fee‑basedpracticing pastoral counselor, a duly licensed physician assistant, a dulylicensed marriage and family therapist, or an advanced practice registerednurse, the insured or other persons entitled to benefits under the policy shallbe entitled to coverage of, payment of, or reimbursement for the services,whether the services be performed by a duly licensed physician, or a provider listedin this subsection, notwithstanding any provision contained in the plan orpolicy limiting access to the providers. The policyholder, insured, orbeneficiary shall have the right to choose the provider of servicesnotwithstanding any provision to the contrary in any other statute, subject tothe utilization review, referral, and prior approval requirements of the planthat apply to all providers for that service; provided that:
(1) In the case of plansthat require the use of network providers as a condition of obtaining benefitsunder the plan or policy, the policyholder, insured, or beneficiary must choosea provider of the services within the network; and
(2) In the case of plansthat require the use of network providers as a condition of obtaining a higherlevel of benefits under the plan or policy, the policyholder, insured, orbeneficiary must choose a provider of the services within the network in orderto obtain the higher level of benefits.
(a2) Whenever any policyof insurance governed by Articles 1 through 64 of this Chapter provides forcertification of disability that is within the scope of practice of a dulylicensed physician, a duly licensed physician assistant, a duly licensedoptometrist, a duly licensed podiatrist, a duly licensed dentist, a dulylicensed chiropractor, a duly licensed clinical social worker, a duly certifiedsubstance abuse professional, a duly licensed professional counselor, a dulylicensed psychologist, a duly certified fee‑based practicing pastoralcounselor, a duly licensed marriage and family therapist, or an advancedpractice registered nurse, the insured or other persons entitled to benefitsunder the policy shall be entitled to payment of or reimbursement for thedisability whether the disability be certified by a duly licensed physician, ora provider listed in this subsection, notwithstanding any provisions containedin the policy. The policyholder, insured, or beneficiary shall have the rightto choose the provider of the services notwithstanding any provision to thecontrary in any other statute; provided that for plans that require the use ofnetwork providers either as a condition of obtaining benefits under the plan orpolicy or to access a higher level of benefits under the plan or policy, thepolicyholder, insured, or beneficiary must choose a provider of the serviceswithin the network, subject to the requirements of the plan or policy.
(a3) Whenever any healthbenefit plan, subscriber contract, or policy of insurance issued by a healthmaintenance organization, hospital or medical service corporation, or insurergoverned by Articles 1 through 67 of this Chapter provides coverage formedically necessary treatment, the insurer shall not impose any limitation ontreatment or levels of coverage if performed by a duly licensed chiropractoracting within the scope of the chiropractor's practice as defined in G.S. 90‑151unless a comparable limitation is imposed on the medically necessary treatmentif performed or authorized by any other duly licensed physician.
(b) For the purposes ofthis section, a "duly licensed psychologist" is a:
(1) Licensedpsychologist who holds permanent licensure and certification as a healthservices provider psychologist issued by the North Carolina Psychology Board;or
(2) Licensed psychologicalassociate who holds permanent licensure.
(c) For the purposes ofthis section, a "duly licensed clinical social worker" is a"licensed clinical social worker " as defined in G.S. 90B‑3(2)and licensed by the North Carolina Social Work Certification and LicensureBoard pursuant to Chapter 90B of the General Statutes.
(c1) For purposes of thissection, a "duly certified fee‑based practicing pastoralcounselor" shall be defined only to include fee‑based practicingpastoral counselors certified by the North Carolina State Board of Examiners ofFee‑Based Practicing Pastoral Counselors pursuant to Article 26 ofChapter 90 of the General Statutes.
(c2) For purposes of thissection, a "duly certified substance abuse professional" is a personcertified by the North Carolina Substance Abuse Professional CertificationBoard pursuant to Article 5C of Chapter 90 of the General Statutes.
(c3) For purposes of thissection, a "duly licensed professional counselor" is a personlicensed by the North Carolina Board of Licensed Professional Counselorspursuant to Article 24 of Chapter 90 of the General Statutes.
(c4) For purposes of thissection, a "duly licensed marriage and family therapist" is a personlicensed by the North Carolina Marriage and Family Therapy Licensure Boardpursuant to Article 18C of Chapter 90 of the General Statutes.
(d) Payment orreimbursement is required by this section for a service performed by anadvanced practice registered nurse only when:
(1) The serviceperformed is within the nurse's lawful scope of practice;
(2) The policy currentlyprovides benefits for identical services performed by other licensed healthcare providers;
(3) The service is notperformed while the nurse is a regular employee in an office of a licensedphysician;
(4) The service is notperformed while the registered nurse is employed by a nursing facility(including a hospital, skilled nursing facility, intermediate care facility, orhome care agency); and
(5) Nothing in thissection is intended to authorize payment to more than one provider for the sameservice.
No lack of signature, referral,or employment by any other health care provider may be asserted to denybenefits under this provision, unless these plan requirements apply to allproviders for that service.
For purposes of this section,an "advanced practice registered nurse" means only a registered nursewho is duly licensed or certified as a nurse practitioner, clinical specialistin psychiatric and mental health nursing, or nurse midwife.
(e) Payment or reimbursementis required by this section for a service performed by a duly licensedpharmacist only when:
(1) The serviceperformed is within the lawful scope of practice of the pharmacist;
(2) The serviceperformed is not initial counseling services required under State or federallaw or regulation of the North Carolina Board of Pharmacy;
(3) The policy currentlyprovides reimbursement for identical services performed by other licensedhealth care providers; and
(4) The service isidentified as a separate service that is performed by other licensed healthcare providers and is reimbursed by identical payment methods.
Nothing in this subsectionauthorizes payment to more than one provider for the same service.
(f) Payment orreimbursement is required by this section for a service performed by a dulylicensed physician assistant only when:
(1) The serviceperformed is within the lawful scope of practice of the physician assistant inaccordance with rules adopted by the North Carolina Medical Board pursuant toG.S. 90‑18.1;
(2) The policy currentlyprovides reimbursement for identical services performed by other licensedhealth care providers; and
(3) The reimbursement ismade to the physician, clinic, agency, or institution employing the physicianassistant.
Nothing in this subsection isintended to authorize payment to more than one provider for the same service.For the purposes of this section, a "duly licensed physicianassistant" is a physician assistant as defined by G.S. 90‑18.1.
(g) A healthmaintenance organization, hospital or medical service corporation, or insurergoverned by Articles 1 through 67 of this Chapter shall not exclude fromparticipation in its provider network or from eligibility to provide particularcovered services under the plan or policy any duly licensed physician orprovider listed in subsection (a1) of this section, acting within the scope ofthe provider's license or certification under North Carolina law, solely on thebasis of the provider's license or certification. Any health maintenanceorganization, hospital or medical service corporation, or insurer governed byArticles 1 through 67 of this Chapter that offers coverage through a networkplan may condition participation in the network on satisfying writtenparticipation criteria, including credentialing, quality, and accessibilitycriteria. The participation criteria shall be developed and applied in a likemanner consistent with the licensure and scope of practice for each type ofprovider. Any health maintenance organization, hospital or medical servicecorporation, or insurer governed by Articles 1 through 67 of this Chapter thatexcludes a provider listed in subsection (a1) of this section fromparticipation in its network or from eligibility to provide particular coveredservices under the plan or policy shall provide the affected listed providerwith a written explanation of the basis for its decision. A health maintenanceorganization, hospital or medical service corporation, or insurer governed byArticles 1 through 67 of this Chapter shall not exclude from participation inits provider network a provider listed in subsection (a1) of this sectionacting within the scope of the provider's license or certification under NorthCarolina law solely on the basis that the provider lacks hospital privileges,unless use of hospital services by the provider on behalf of a policy holder,insured, or beneficiary reasonably could be expected.
(h) Nothing in thissection shall be construed as expanding the scope of practice of any duly licensedphysician or provider listed in subsection (a1) of this section. (1913, c. 91, s. 11; C.S., s.6488; 1965, c. 396, s. 2; c. 1169, s. 2; 1967, c. 690, s. 2; 1969, c. 679;1973, c. 610; 1977, c. 601, ss. 2, 31/2; 1991, c. 720, s. 29; 1993, c. 347, s.2; c. 375, s. 3; c. 464, s. 2; c. 554, s. 1; 1995, c. 193, s. 41, c. 223, s. 1;c. 406, s. 3; 1997‑197, ss. 1, 2; 1999‑186, s. 1; 1999‑199,s. 1; 1999‑210, s. 2; 2001‑297, s. 1; 2001‑446, s. 1.7; 2001‑487,s. 40(g); 2003‑117, s. 1; 2003‑368, s. 1; 2005‑276, s. 6.29;2005‑345, ss. 3(a), 3(b); 2007‑24, s. 1.)