2014 Kentucky Revised Statutes CHAPTER 304 - INSURANCE CODE Subtitle 17A - Health Benefit Plans 17A.17A-577 Disclosure of payment or fee schedule to managed care plan health care provider -- Disclosure of schedule change -- Confidentiality of payment information.
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304.17A-577 Disclosure of payment or fee schedule to managed care plan
health care provider -- Disclosure of schedule change -- Confidentiality of
payment information.
(1)
(2)
(3)
(a)
An insurer issuing a managed care plan shall, upon request of a health
care provider, provide or make available to the health care provider, when
contracting or renewing an existing contract with such provider, the
payment or fee schedules or other information sufficient to enable the
health care provider to determine the manner and amount of payments
under the contract for the health care provider's services prior to final
execution or renewal of the contract. The payment or fee schedule or
other information submitted to a health care provider pursuant to this
section shall include a description of processes and factors that may be
applicable and that may affect actual payment, including copayments,
coinsurance, deductibles, risk sharing arrangements, and liability of third
parties. Nothing in this paragraph shall prohibit a plan from making any
part of the information requested available electronically or via a Web site.
(b) An insurer issuing a managed care plan, upon request of a health care
provider, shall provide or make available to the health care provider an
explanation of the methodology, such as relative value unit system and
conversion factor, percentage of Medicare payment system, or
percentage of billed charges, used to determine actual payment for
procedures frequently performed by the provider that involve
combinations of services or payment codes, if the actual payment for the
procedures cannot be ascertained from the fee schedule or other
information submitted to a health care provider pursuant to this section.
As applicable, the methodology disclosure provided for in this paragraph
shall include:
1.
The name of any relative value system;
2.
The version, edition, or publication date of the relative value system;
and
3.
Any applicable conversion or geographic factor.
Nothing in this paragraph shall prohibit a plan from making any part of the
information requested available electronically or via a Web site.
(c) The provisions of this subsection requiring the submission of a fee
schedule or other information upon renewal of an existing contract shall
not be applicable to renewal of an existing contract when the payment or
fee schedule previously provided to the health care provider has not
changed.
Any change to payment or fee schedules applicable to providers under
contract with an insurer issuing a managed care plan shall be made available
to such providers at least ninety (90) days prior to the effective date of the
amendment. This subsection shall not apply to changes in standard codes and
guidelines developed by the American Medical Association or a similar
organization.
A health care provider receiving information pursuant to subsection (1) of this
section shall not share this information with an unrelated person without the
prior written consent of the insurer issuing a managed care plan. The remedies
available to an insurer issuing a managed care plan to enforce the provision of
this subsection shall include without limitation injunctive relief. An insurer
issuing a managed care plan seeking extraordinary relief to enforce this section
shall not be required to establish irreparable harm with regard to the sharing of
competitively sensitive information.
Effective:July 15, 2008
History: Created 2008 Ky. Acts ch. 169, sec. 3, effective July 15, 2008.
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