§ 26.1-47-02 — Preferred provider arrangements

North Dakota § 26.1-47-02

• Jurisdiction: North Dakota
• Title 26.1: Insurance
• Ch. 26.1-47: Preferred Provider Organizations

Text

Notwithstanding any provision of law to the contrary, any health care insurer may enter into
preferred provider arrangements.
1. Preferred provider arrangements must:
a. Establish the amount and manner of payment to the preferred provider. The
amount and manner of payment may include capitation payments for preferred
providers.
b. Include mechanisms, subject to the minimum standards imposed by chapter
26.1-26.4, which are designed to review and control the utilization of health care
services and establish a procedure for determining whether health care services
rendered are medically necessary.
c. Include mechanisms which are designed to preserve the quality of health care.
d. With regard to an arrangement in which the preferred provider is placed at risk for
the cost or utilization of health care services, specifically include a description of
the preferred provider's responsibilities with respect to the health care insurer's
applicable administrative policies and programs, including utilization review,
quality assessment and improvement programs, credentialing, grievance
procedures, and data reporting requirements. Any administrative responsibilities
or costs not specifically described or allocated in the contract establishing the
arrangement as the responsibility of the preferred provider are the responsibility
of the health care insurer.
e. Provide that in the event the health care insurer fails to pay for health care
services as set forth in the contract, the covered person is not liable to the
provider for any sums owed by the health care insurer.
f. Provide that in the event of the health care insurer insolvency, services for a
covered person continue for the period for which premium payment has been
made and until the covered person's discharge from inpatient facilities.
g. Provide that either party terminating the contract without cause provide the other
party at least sixty days' advance written notice of the termination.
2. Preferred provider arrangements may not unfairly deny health benefits to persons for
covered medically necessary services.
3. Preferred provider arrangements may not restrict a health care provider from entering
into preferred provider arrangements or other arrangements with other health care
insurers.
4. A health care insurer must file all its preferred provider arrangements with the
commissioner within ten days of implementing the arrangements. If the preferred
provider arrangement does not meet the requirements of this chapter, the
commissioner may declare the contract void and disapprove the preferred provider
arrangement in accordance with the procedure for policies set out in chapter 26.1-30.
5. A preferred provider arrangement may not offer an inducement to a preferred provider
to provide less than medically necessary services to a covered person. This
subsection does not prohibit a preferred provider arrangement from including
capitation payments or shared-risk arrangements authorized under subdivision a of
subsection 1 which are not tied to specific medical decisions with respect to a patient.
6. A health care insurer may not penalize a provider because the provider, in good faith,
reports to state or federal authorities any act or practice by the health care insurer
which jeopardizes patient health or welfare.