Source: http://www.dfr.vermont.gov/reg-bul-ord/health-insurance-claims-administration-rule-0
Timestamp: 2017-10-20 03:22:19
Document Index: 565266192

Matched Legal Cases: ['§ 9408', '§ 9408', '§ 15', '§ 9404', '§ 4089', '§9418']

Health Insurance Claims Administration Rule | Department of Financial Regulation
Home |Health Insurance Claims Administration Rule
Health Insurance Claims Administration Rule
Reg. H-2008-04
Printer-friendly version of Regulation H-2008-04 223.2 KB
Sample Doctor Bill 31.45 KB
Sample Hospital Bill 63.83 KB
Sample EOB 23.42 KB
Rule No. H-2008-04
(b) The goals of this Rule are set forth in 18 V.S.A. § 9408 and Sec. 55 of Act 191 (2006): (1) simplifying the claims administration process for consumers, health care providers, and others so that the process is more understandable and less time-consuming; and (2) lowering administrative costs in the health care financing system.
This Rule is adopted pursuant to the authority vested in the Commissioner by law, including but not limited to 18 V.S.A. § 9408, 8 V.S.A. § 15(a), 18
V.S.A. § 9404, and Sec. 55 of Act 191 (2006).
(3) “Health Care Provider” means:
(4) “Health Claim” means a health care claim for reimbursement or approval or any other transaction related to a health claim between a Health Care Provider and a Health Insurer.
(5) “Health Insurer” means:
(iii) any agents or affiliates of the Health Insurer who contract to administer the benefits covered or administered by the Health Insurer, such as pharmacy benefit managers, radiology benefit managers, and mental health services review agents licensed under 8 V.S.A. § 4089a; and
(6) “Rule” means the administrative rule adopted herein.
Section 5. Establishment of the Vermont Claims Administration Collaborative
(a)(1) The Commissioner shall contract with the Vermont Program for Quality in Health Care, Inc. (“VPQHC”), or some other suitable contractor designated by the Commissioner, to facilitate and provide administrative support for a claims administration initiative to be established, implemented, and known as the Vermont Claims Administration Collaborative.
(4) The Commissioner or the Commissioner’s designee, shall be a member of the Collaborative. The Commissioner shall appoint a Chair of the Collaborative. The Commissioner, in consultation with the members of the Collaborative, shall establish rules of procedure for the Collaborative, including membership eligibility rules and anti-trust guidelines.
(b) On or about January 1 of each year, the Commissioner or the Commissioner’s designee, after consultation with the members of the Vermont Claims Administration Collaborative, shall establish an annual agenda for the Collaborative. The Vermont Claims Administration Collaborative shall make recommendations to the Commissioner for the adoption by the Commissioner of claims administration and adjudication standards pursuant to the administrative rule-making process. The Commissioner may adopt the recommended standard with or without amendment, provided that if the Commissioner proposes to amend the standard recommended by the Collaborative, the Commissioner shall request the Collaborative to consider the amendment before the standard is filed as a proposed administrative rule with the Secretary of State under 3 V.S.A. section 838. Notwithstanding the inability of the Collaborative to agree upon a recommendation with respect to a standard included in the annual agenda, the Commissioner may amend or adopt a rule to include such a standard. The Commissioner’s authority to adopt rules as set forth in this Rule is in addition to any other rule-making authority established by law.
(c) In developing standards for the Commissioner, the Vermont Claims Administration Collaborative shall consult with national standard setting entities including but not limited to Centers for Medicare and Medicaid Services (CMS), the National Uniform Claim Form Committee, the American National Standards Institute, the Council for Affordable Quality Healthcare’s (“CAQH”) Committee on Operating Rule Exchange (“CORE”) and the National Uniform Billing Committee.
Section 6. Claims Administration and Adjudication Standards
EOB Formats
(B) EOB Minimum Required Elements
(Includes as a minimum, inpatient, outpatient, office visit, and pharmacy or a detailed description of the service rendered)
5. Not Covered/Not Allowed:
with subcategories of Not Due From Patient and Due From Patient
(C) EOB Terms and Definitions
Required Term Required Minimum Definition
The provider who billed your plan for the service.
The date you received the services recorded on the statement.
Billed Charges service
Amount billed for the
Any billed charges not covered by your policy including services provided by an out-of- network or non- participating provider.
Not Allowed your plan.
An adjustment made by
Not Due From Patient
The amount your plan will allow for this service
Any payment made by another policy that covers you.
The fixed dollar amount you are required to pay your service provider for this service.
An amount you must pay toward the cost of services each Plan year before your Plan pays any benefot
The percentage of the allowed amount(s) that you are required to pay your provider.
Total Due from Patient
The amount the provider may bill you.
A code that provides additional information.
(D) The EOB shall account for all applicable contract benefits, including out-of-pocket requirements and contracted provider discounts, against each billed charge for each service on the EOB. The EOB will clearly show the amount owed by the member to the provider, if any, for each service on the EOB and be mathematically accurate. EOBs shall be sent to the consumer within the payment guidelines of 18 V.S.A. §9418.
(E) Implementation Date. This standard shall be fully implemented by all Health Insurers on or of before Oct 1, 2010.
(F) Member Satisfaction. Each Health Insurer shall be required to track member satisfaction with the Health Insurer’s EOB. This may be accomplished by query of their internal phone tracking system or by survey, and shall be performed every other year. A baseline measurement of member satisfaction shall occur no later than April 1, 2011. Results and recommended changes shall be made available to VCAC within forty-five days of completion of the query or survey.
(G) Office of Vermont Health Access (OVHA). OVHA shall be excluded from the requirements of this Section (1), Standards for EOBs, for Medicaid beneficiaries.
(A) Sample Patient Bills are provided. Hospitals, Federally- Qualified Health Centers (FQHCs), Providers and Billing Service Providers (hereinafter “Billing Entities”) that adopt this format will be in compliance with this rule. Billing Entities shall maximize the visual clarity of Patient Bills to achieve optimum readability and be consistent with H-2009-03 or any subsequent replacement Rule(s). The font size should be as large as possible. Patient Bills adopted by Billing Entities with other formats, additions to the minimum required elements or enhancement of the terms and definitions, which are found by the Commissioner to be confusing to the general public or do not adequately provide for visual clarity, may be subject to review and disapproval with or without conditions by the Department.
2. Billing Entities’ branding and logos can be individualized and placed anywhere on the Patient Bills.
Required Term Required
The date you received the services recorded on this bill.
Amount billed for the service
The amount that your provider and/or your plan have agreed to discount from the billed charge.
The dollar amount you have paid
2. The standards shall also apply to health benefit plans offered or administered by the Office of Vermont Health Access (OVHA), with the exception of effective date, group or account number, and co-pay elements.
3. ID Cards issued by insurers for medical and mental health services, and health benefit plans administered by OVHA, shall comply with Health Insurance Portability and Accountability Act of 1996’s ID Card requirements or any other related federal or state regulation.
(B) Minimum Required ID Card Elements
All ID cards shall include the set of required elements shown below. Health insurers may enhance ID Cards by including additional elements or information to the required set of elements listed below, at their discretion.
(e.g. pharmacy benefits, pre-certification, mental health/substance abuse)
7. Visit co-payments are required, when contractually applicable, for at least primary care office visits, specialist office visits and hospital emergency room visits.
BISHCA Regulation 93-4, “Uniform Claim Forms and Uniform Standards and Procedures for Processing” will be amended as Section 6 standards are adopted.
This Rule shall take effect on April 21, 2009. Previously amended effective February 1, 2010.
Amended effective April 1, 2010