Provider Contract Standards
See bold sections below:
I. Every contract between a health carrier and a participating provider shall set forth a hold harmless provision specifying protection for covered persons. This provision shall include language substantially as follows:
(a) Provider agrees that in no event, including but not limited to nonpayment by the health carrier or intermediary, insolvency of the health carrier or intermediary, or breach of this agreement, shall the provider bill, charge, collect a deposit from, seek payment or reimbursement from, or have recourse against a covered person or a person acting on behalf of the covered person (other than the health carrier or intermediary) for services provided pursuant to this agreement. This agreement does not prohibit the provider from collecting coinsurance, deductibles, or copayments, as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to covered persons. Nor does this agreement prohibit a provider and a covered person from agreeing to continue services solely at the expense of the covered person, as long as the provider has clearly informed the covered person that the health carrier may not cover or continue to cover a specific service or services. Except as provided in this chapter, this agreement does not prohibit the provider from pursuing any available legal remedy.
(b) Provider further agrees that:
(1) This provision shall survive the termination of this agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the covered person; and that
(2) This provision supersedes any oral or written contrary agreement now existing or hereafter entered into between provider and covered person or persons acting on their behalf.
(c) Any modifications, additions or deletions to the provisions of this section shall become effective on a date no earlier than 15 business days after the commissioner has received written notice of such proposed changes.
Liability-Insurer Shifting to Physician
II. The execution of a contract by a health carrier shall not relieve the health carrier of its liability to any person with whom it has contracted for the provision of services, nor of its responsibility for the compliance with any law or rule.
III. The health carrier shall maintain provider and intermediary contracts at its principal place of business in this state, or the health carrier shall have access to all contracts and provide copies to facilitate regulatory review upon 15 business days prior written notice from the commissioner.
Liability-Insurer Shifting to Physician
IV. No contract between a health carrier and a physician, for the purpose of delineating the rights and obligations of the parties within the provider network, shall limit the liability of the health carrier for any actions of the physician for which the health carrier might otherwise be liable.
V. No contract between a health carrier and a health care provider shall limit what information such health care provider may disclose to patients or to prospective patients regarding the provisions, terms, or requirements of the health carrier’s products as they relate to the needs of such provider’s patients except for trade secrets of significant competitive value.
VI. No contract shall use the term physician for the purpose of allowing a health carrier to avoid contracting with other health care professionals for health care services. A physician shall mean a person licensed to practice medicine under RSA 329. Nothing in this section shall be construed to require a health carrier to contract with a health care provider.
VII. A health carrier shall allow a participating provider 60 days from the postmarked date to review any proposed contract and any modifications to an existing contract, excluding those modifications that are expressly permitted under the existing contract.
Prohibited Financial Incentives
VIII.(a) No contract between a health carrier and a participating provider shall contain any payment or reimbursement provision the terms of which creates an inducement for the provider to not provide medically necessary care to covered persons. Nothing in this section shall be construed to prohibit the use of payment arrangements between a health carrier and a participating provider or provider group which involve capitation, withholds or other arrangements.
(b) Prior to the execution of a health care provider contract, a health carrier shall furnish to the contracting entity, in writing or in electronic format, a complete copy of the proposed contract including all attachments and exhibits. The health carrier shall also make available to the contracting entity, in writing or in electronic format, the most current provider manual.
(c) The contracting entity may request that a health carrier disclose the fees applicable to specified procedure codes that pertain to the entity’s practice or specialty or a method or process that allows the contracting entity to determine the fees pursuant to the terms of the contract. Upon request by the contracting entity, the insurer shall furnish, in writing or in an electronic format, the requested procedure codes within 30 calendar days from receipt of the request.
Fee Schedules; Amendments
(d) No provider contract shall allow for a material change in the applicable fee schedule unless notice of such change is given at least 60 days in advance of the effective date.
(e) Provider contracts that include payment for mammography shall include distinct recognition of and additional payment for industry standard coding relating to mammography screening using 3-D tomosynthesis.
IX. The health carrier shall provide to covered persons, in the evidence of coverage, a description for the types of financial arrangements contained in its contracts with participating providers. Such descriptions shall be set forth in clear, understandable language.
X. Every contract between a health carrier and a participating provider shall provide that the health carrier may not remove a health care provider from its network or refuse to renew the health care provider with its network for participating in a covered person’s internal grievance procedure or external review.
Continuity of Care Post-Contract
XI. Every contract entered into after July 1, 2003 between a health carrier and any physician or facility shall contain a provision that ensures that covered persons will have continued access to the provider in the event that the contract is terminated for any reason other than unprofessional behavior. The continued access to providers shall be made available for 60 days from the date of termination of the contract and shall be provided and paid for in accordance with the terms and conditions of the covered person’s health benefit plan and the prior contract between a health carrier and a health care provider. Within 5 business days of the contract termination, the health carrier shall provide written notice to affected covered persons explaining their continued access rights.
XIII. No health carrier shall interfere with a provider’s right to legal representation during contract negotiations by restricting the provider’s right to share confidential information with counsel or by refusing to negotiate directly with counsel selected by a provider as long as the provider receives assurance that counsel agrees to keep confidential the information exchanged during the course of negotiations to the same extent the provider is obligated to keep such information confidential.
XIV. Every contract or contract amendment entered into after the effective date of this paragraph between a health care carrier and any provider or facility shall contain a provision stating that no provider employed by a hospital or any affiliate is required or in any way obligated to refer patients to providers also employed or under contract with the hospital or any affiliate. Nothing in this paragraph shall be construed to prohibit health care carriers from providing coverage for only those services which are medically necessary and subject to the terms and conditions of the covered person’s policy.
XV.(a) All contracts between a carrier or pharmacy benefit manager and a contracted pharmacy shall include:
(1) The sources used by the pharmacy benefit manager to calculate the drug product reimbursement paid for covered drugs available under the pharmacy health benefit plan administered by the carrier or pharmacy benefit manager.
(2) A process to appeal, investigate, and resolve disputes regarding the maximum allowable cost pricing. The process shall include the following provisions:
(A) A provision granting the contracted pharmacy or pharmacist at least 30 business days following the initial claim to file an appeal;
(B) A provision requiring the carrier or pharmacy benefit manager to investigate and resolve the appeal within 30 business days;
(C) A provision requiring that, if the appeal is denied, the carrier or pharmacy benefit manager shall:
(i) Provide the reason for the denial; and
(ii) Identify the national drug code of a drug product that may be purchased by contracted pharmacies at a price at or below the maximum allowable cost; and
(D) A provision requiring that, if an appeal is granted, the carrier or pharmacy benefits manager shall within 30 business days after granting the appeal:
(i) Make the change in the maximum allowable cost; and
(ii) Permit the challenging pharmacy or pharmacist to reverse and rebill the claim in question.
(b) For every drug for which the pharmacy benefit manager establishes a maximum allowable cost to determine the drug product reimbursement, the pharmacy benefit manager shall:
(1) Include in the contract with the pharmacy information identifying the national drug pricing compendia or sources used to obtain the drug price data.
(2) Make available to a contracted pharmacy the actual maximum allowable cost for each drug.
(3) Review and make necessary adjustments to the maximum allowable cost for every drug for which the price has changed at least every 14 days.
(d) A pharmacy benefit manager shall not require accreditation of providers other than requirements set forth by the New Hampshire pharmacy board or other state or federal entity.
XVI. No contract between an insurance carrier or pharmacy benefit manager and a contracted pharmacy shall contain a provision prohibiting divulgence to a covered person or the insurance department relative to monetary matters which would prove beneficial in lowering costs to such covered person.