I.In this section, "health carrier" means a health carrier as defined in RSA 420-G:2 and any health insurer; administrator of self-insured plans, group health plans, as defined in section 607(1) of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. section 1167(1), and service benefit plans; any third party administrator of health benefits, provider of health benefits under an ERISA plan, or provider of health benefits under a self administered plan; health management organizations, health service corporations, managed care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service. II.Each health carrier shall electronically cross-match claims da
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I. In this section, "health carrier" means a health carrier as defined in RSA 420-G:2 and any health insurer; administrator of self-insured plans, group health plans, as defined in section 607(1) of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. section 1167(1), and service benefit plans; any third party administrator of health benefits, provider of health benefits under an ERISA plan, or provider of health benefits under a self administered plan; health management organizations, health service corporations, managed care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.
II. Each health carrier shall electronically cross-match claims data, policyholder, and subscriber information with the department of health and human services to provide health insurance coverage information, for third party liability purposes, regarding medical assistance recipients and applicants for medical assistance under RSA 167 in accordance with rules adopted by the commissioner of health and human services pursuant to RSA 167:3-c.
III. Such electronic cross-match shall be made by any health carrier upon certification by the department of health and human services that all persons identified on the electronic medium are applicants for or recipients of medical assistance for which the department seeks payment or reimbursement through third party liability. A health carrier shall limit the transfer of electronic cross-match information required under this section to a list of medical assistance recipients and applicants for medical assistance under RSA 167 provided to the health carrier by the department of health and human services.
IV. Any health carrier who supplies information in accordance with this section and with rules adopted under RSA 167:3-c shall have immunity from any civil or criminal liability that might otherwise be imposed or incurred.
V. Each health carrier shall:
(a) Accept the state's, or its designated managed care organizations', and/or contractor's or its assigned designee's, right of recovery and assignment to the state or its designated managed care organizations of any right of an individual or other entity to payment from the party for an item or service for which payment has been made under the state plan.
(b) Respond to any inquiry by the state, or its designated managed care organizations, and/or contractor or its assigned designee, within 60 calendar days from the date the inquiry is sent, regarding a claim for payment for any health care item or service that is submitted not later than 3 years after the date of the provision of such health care item or service and action taken on the claim commenced within 6 years of the submission of the claim for payment.
(c) Not deny a claim submitted by the state, or its designated managed care organizations, and/or contractor or its assigned designee:
(1) Solely on the basis of the date of submission of the claim;
(2) For specific type of format of the claim form, including that the responsible third party cannot require claims to be submitted on national claim forms or electronically;
(3) For unknown or unavailable policyholder information or coordination of benefits authorization from the policyholder;
(4) For failure to present proper documentation at the point-of-sale that is the basis of the claim;
(5) For the state or its designated managed care organizations not having a National Provider Identifier (NPI) on the submitted claim; or
(6) For not obtaining the responsible third party's prior authorization for items or services paid by the state or its designated managed care organizations. The responsible third party shall deem the state's or its designated managed care organizations' payment of a claim for a medical item or service to be the equivalent of the medical assistance recipient having obtained prior authorization for the item or service from the third party.
VI. A health carrier may not refuse to furnish payment, benefits, or services to an individual or refuse to enroll an individual based upon the individual's eligibility for medical assistance under Title XIX of the Social Security Act.