§ 27-20.10-4 - Contracting entity rights and responsibilities.
SECTION 27-20.10-4
§ 27-20.10-4 Contracting entity rights andresponsibilities. – (a) A contracting entity may not grant access to a provider's health careservices and contractual discounts pursuant to a provider network contractunless:
(1) The provider network contract specifically states thatthe contracting entity may enter into an agreement with a third-party allowingthe third-party to obtain the contracting entity's rights and responsibility'sunder the provider network contract as if the third-party were the contractingentity; and
(2) The third-party accessing the provider network contractis contractually obligated to comply with all applicable terms, limitations andconditions of the provider network contract.
(b) A contracting entity that grants access to a provider'shealth care services and contractual discounts pursuant to a provider networkcontract shall:
(1) Identify and provide to the provider, upon request at thetime a provider network contract is entered into with a provider, a written orelectronic list of all third-parties known at the time of contracting, to whichthe contracting entity has or will grant access to the provider's health careservices and contractual discounts pursuant to a provider network contract;
(2) Maintain an Internet website or other readily availablemechanism, such as a toll-free telephone number, through which a provider mayobtain a listing, updated at least every ninety (90) days, of the third-partiesto which the contracting entity or another third-party has executed contractsto grant access to such provider's health care services and contractualdiscounts pursuant to a provider network contract;
(3) Provide each third-party who contracts with thecontracting entity to gain access to the provider network contract with asummary of the contracting entity's current standard provider contract terms;
(4) Require that the third-party who contracts with thecontracting entity to gain access to the provider network contract identify thesource of the contractual discount taken by the third- party on each remittanceadvice (RA) or explanation of payment (EOP) form furnished to a health careprovider when such discount is pursuant to the contracting entity's providernetwork contract;
(5) Notify the third-party who contracts with the contractingentity to gain access to the provider network contract of the termination ofthe provider network contract no later than ten (10) days after receipt ofnotice of the termination of the provider network contract;
(ii) Require those that are by contract eligible to claim theright to access a provider's discounted rate to cease claiming entitlement tothose rates or other contracted rights or obligations for services renderedafter termination of the provider network contract; and
(iii) The notice required under paragraph (i) above can beprovided through any reasonable means, including, but not limited to: writtennotice, electronic communication, or an update to electronic database or otherprovider listing.
(c) Subject to any applicable continuity of carerequirements, agreements, or contractual provisions:
(1) A third-party's right to access a provider's health careservices and contractual discounts pursuant to a provider network contractshall terminate on the date the provider network contract is terminated;
(2) Claims for health care services performed after thetermination date of the provider network contract are not eligible forprocessing and payment in accordance with the provider network contract; and
(3) Claims for health care services performed before thetermination date of the provider network contract, but processed after thetermination date, are eligible for processing and payment in accordance withthe provider network contract.
(d) All information made available to provider in accordancewith the requirements of this chapter shall be confidential and shall not bedisclosed to any person or entity not involved in the provider's practice orthe administration thereof without the prior written consent of the contractingentity.
(2) Nothing contained in this chapter shall be construed toprohibit a contracting entity from requiring the provider to execute areasonable confidentiality agreement to ensure that confidential or proprietaryinformation disclosed by the contracting entity is not used for any purposeother than the provider's director practice management or billing activities.