2016 Kentucky Revised Statutes CHAPTER 304 - INSURANCE CODE Subtitle 17A - Health Benefit Plans 304.17A-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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