§460.75. Provider claim payment and information protection
A.If a healthcare provider submits a request, either orally or in writing, to a managed
care organization during the time prescribed by state law or regulation in which a managed
care organization can subject a claim to any review or audit for purposes of reconsidering the
validity of a claim, the managed care organization shall provide, within two business days
of such request, a copy of all documentation that has been transmitted between the healthcare
provider and the managed care organization, or their respective agents, that is associated with
a claim for payment of a service. A managed care organization may, in lieu of providing a
physical copy, provide electronic access of the documentation through the use of a provider
por
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§460.75. Provider claim payment and information protection
A. If a healthcare provider submits a request, either orally or in writing, to a managed
care organization during the time prescribed by state law or regulation in which a managed
care organization can subject a claim to any review or audit for purposes of reconsidering the
validity of a claim, the managed care organization shall provide, within two business days
of such request, a copy of all documentation that has been transmitted between the healthcare
provider and the managed care organization, or their respective agents, that is associated with
a claim for payment of a service. A managed care organization may, in lieu of providing a
physical copy, provide electronic access of the documentation through the use of a provider
portal or other electronic means to the provider. All information or documentation required
to be provided to a healthcare provider by a managed care organization pursuant to this
Section, whether by physical copy or electronic access, shall be provided at no cost to the
healthcare provider.
B.(1) Any healthcare provider contract issued, amended, or renewed on or after
January 1, 2021, between a managed care organization, its contracted vendor, or agent and
a healthcare provider for the provision of healthcare services to a Medicaid enrollee shall not
contain restrictions on methods of payment from the managed care organization or its vendor
to the healthcare provider in which the only acceptable payment method for healthcare
services rendered requires the healthcare provider to pay a transaction fee, provider
subscription fee, or any other type of fee or cost in order to accept payment from the
managed care organization for the provision of healthcare services, or that would result in
a monetary reduction in the healthcare provider's payment for the healthcare services
rendered.
(2) If initiating or changing payments to a healthcare provider using electronic funds
transfer payments a managed care organization, its contracted vendor, or agent shall do both
of the following:
(a) Notify the healthcare provider if any fees are associated with a particular payment
method.
(b) Advise the provider of the available methods of payment and provide clear
instructions to the healthcare provider as to how to select an alternative payment method that
does not require the healthcare provider to pay a transaction fee, provider subscription fee,
or any other type of fee or cost in order to accept payment from the managed care
organization for the provision of healthcare services.
C. The provisions of this Section shall not be waived by contract, and any contractual
clause in conflict with the provisions of this Section or that purports to waive any
requirements of this Section is void.
D. If the managed care organization, its contracted vendor, or agent violates any
provision of this Section, the department shall impose penalties on the managed care
organization in accordance with contract provisions or rules and regulations promulgated
pursuant to the Administrative Procedure Act, except that penalties shall be imposed without
the necessity of the department having to issue any prior notice of corrective action.
E. As used in this Section, "electronic funds transfer" means an electronic funds
transfer through the federal Health Insurance Portability and Accountability Act of 1996, P.L.
104-191, standard automated clearinghouse network.