US Laws, Codes, Statutes & Cases

                                  TITLE  41
                                  INSURANCE
                                  CHAPTER 39
                             MANAGED CARE REFORM
    41-3927.  HEALTH CARE PROVIDERS -- PARTICIPATION BY ANY QUALIFIED, WILLING
PROVIDER -- CONTRACTS -- GRIEVANCE PROCEDURE. (1) Any managed care
organization issuing benefits pursuant to the provisions of this chapter shall
be ready and willing at all times to enter into care provider service
agreements with all qualified providers of the category or categories which
are necessary to provide the health care services covered by an organization
if the health care providers: are qualified under the laws of the state of
Idaho, desire to become participant providers of the organization, meet the
requirements of the organization, and practice within the general area served
by the organization.
    (2)  Nothing in this section shall preclude an organization from refusing
to contract with a provider who is unqualified or who does not meet the terms
and conditions of the organization's participating provider contract or from
terminating or refusing to renew the contract of a health care provider who is
unqualified or who does not comply with, or who refuses to comply with, the
terms and conditions of the participating provider contract including, but not
limited to, practice standards and quality requirements. The contract shall
provide for written notice to the participating health care provider setting
forth any breach of contract for which the organization proposes that the
contract be terminated or not renewed and shall provide for a reasonable
period of time for the participating health care provider to cure such breach
prior to termination or nonrenewal. If the breach has not been cured within
such period of time the contract may be terminated or not renewed. Provided
however, that if the breach of contract for which the organization proposes
that the contract be terminated or not renewed is a willful breach, fraud or a
breach which poses an immediate danger to the  public health or safety, the
contract may be terminated or not renewed immediately.
    (3)  Every managed care organization issuing benefits pursuant to this
chapter shall establish a grievance system for providers. Such grievance
system shall provide for arbitration according to chapter 9, title 7, Idaho
Code, or for such other system which provides reasonable due process
provisions for the resolution of grievances and the protection of the rights
of the parties.
    (4)  No managed care organization may require as an element of any
provider contract that any person agree:
    (a)  To deny a member access to services not covered by the managed care
    plan if the member is informed that he will be responsible to pay for the
    noncovered services and the member nonetheless desires to obtain such
    services;
    (b)  To refrain from treating a member even at that member's request and
    expense if the provider had been, but is no longer, a contracting provider
    under the managed care plan and the provider has notified the member that
    the provider is no longer a contracting provider under the managed care
    plan;
    (c)  To the unnegotiated adjustment by the managed care organization of
    the provider's contractual reimbursement rate to equal the lowest
    reimbursement rate the provider has agreed to charge any other payor;
    (d)  To a requirement that the provider adjust, or enter into negotiations
    to adjust, his or her charges to the managed care organization if the
    provider agrees to charge another payor lower rates; or
    (e)  To a requirement that the provider disclose his or her contractual
    reimbursement rates from other payors.
    (5)  A managed care organization shall not refuse to contract with or
compensate for covered services an otherwise eligible provider or
nonparticipating provider solely because the provider has in good faith
communicated with one (1) or more current, former, or prospective patient
regarding the provisions, terms or requirements of the organization's products
as they relate to the needs of the provider's patients.
    (6)  As part of a provider contract, a managed care organization may
require a provider to indemnify and hold harmless the managed care
organization under certain circumstances so long as the managed care
organization also agrees to indemnify and hold harmless the provider under
comparable circumstances.
    (7)  On request and within a reasonable time, a managed care organization
shall make available to any party to a provider contract any documents
referred to or adopted by reference in the contract except for information
which is proprietary or a trade secret or confidential personnel records.
    (8)  A managed care organization shall permit a contracting provider who
is practicing in conformity with community standards to advocate for his
patient without being subject to termination or penalty for the sole reason of
such advocacy.
    (9)  Subsections (1) and (2) of this section shall apply to provider
participation contracts entered into after July 1, 1994.