Title 27
Insurance

Chapter 20.10
Rental Network Contract Arrangements

§ 27-20.10-4. Contracting entity rights and responsibilities.

(a) A contracting entity may not grant access to a provider’s healthcare services and contractual discounts pursuant to a provider network contract unless:

(1) The provider network contract specifically states that the contracting entity may enter into an agreement with a third party allowing the third party to obtain the contracting entity’s rights and responsibilities under the provider network contract as if the third party were the contracting entity; and

(2) The third party accessing the provider network contract is contractually obligated to comply with all applicable terms, limitations, and conditions of the provider network contract.

(b) A contracting entity that grants access to a provider’s healthcare services and contractual discounts pursuant to a provider network contract shall:

(1) Identify and provide to the provider, upon request at the time a provider network contract is entered into with a provider, a written or electronic list of all third parties known at the time of contracting, to which the contracting entity has or will grant access to the provider’s healthcare services and contractual discounts pursuant to a provider network contract;

(2) Maintain an Internet website or other readily available mechanism, such as a toll-free telephone number, through which a provider may obtain a listing, updated at least every ninety (90) days, of the third parties to which the contracting entity or another third party has executed contracts to grant access to such provider’s healthcare services and contractual discounts pursuant to a provider network contract;

(3) Provide each third party who contracts with the contracting entity to gain access to the provider network contract with a summary of the contracting entity’s current standard provider contract terms;

(4) Require that the third party who contracts with the contracting entity to gain access to the provider network contract identify the source of the contractual discount taken by the third party on each remittance advice (RA) or explanation of payment (EOP) form furnished to a healthcare provider when such discount is pursuant to the contracting entity’s provider network contract;

(5)(i) Notify the third party who contracts with the contracting entity to gain access to the provider network contract of the termination of the provider network contract no later than ten (10) days after receipt of notice of the termination of the provider network contract;

(ii) Require those that are by contract eligible to claim the right to access a provider’s discounted rate to cease claiming entitlement to those rates or other contracted rights or obligations for services rendered after termination of the provider network contract; and

(iii) The notice required under paragraph (i) above can be provided through any reasonable means, including, but not limited to: written notice, electronic communication, or an update to electronic database or other provider listing.

(c) Subject to any applicable continuity of care requirements, agreements, or contractual provisions:

(1) A third party’s right to access a provider’s healthcare services and contractual discounts pursuant to a provider network contract shall terminate on the date the provider network contract is terminated;

(2) Claims for healthcare services performed after the termination date of the provider network contract are not eligible for processing and payment in accordance with the provider network contract; and

(3) Claims for healthcare services performed before the termination date of the provider network contract, but processed after the termination date, are eligible for processing and payment in accordance with the provider network contract.

(d)(1) All information made available to a provider in accordance with the requirements of this chapter shall be confidential and shall not be disclosed to any person or entity not involved in the provider’s practice or the administration thereof without the prior written consent of the contracting entity.

(2) Nothing contained in this chapter shall be construed to prohibit a contracting entity from requiring the provider to execute a reasonable confidentiality agreement to ensure that confidential or proprietary information disclosed by the contracting entity is not used for any purpose other than the provider’s director practice management or billing activities.