Specifies time lines for QHP claims processing and payment. Established a disputed claims resolution process under the direction of the Insurance Commissioner. Requires QHPs to have standardized electronic claims processing systems. Requires QHPs and contracted health care providers to use nationally recognized procedure codes. Specifies those medical procedures that may require prior authorization.
State assumes full risk for pharmaceutical product price inflation.
QHPs and Community Mental Health Boards assume full risk for enrollee prescription utilization rates based upon pre-established utilization standards. Recalculate ABD capitation rates by removing expenditures related to high cost cases. Use the savings from the reduced capitation rate to fund a risk adjustor pool. QHPs will be eligible for payments from this pool based upon a formula reflecting the proportion of ABD enrollees to the total ABD population and the proportion of ABD enrollees to total enrollees. Be fully capable of meeting standardized electronic claims processing standards.