reglab/housing_qa huggingface dataset:
NH Rev Stat § 420-J:6-b (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:6-b - Self-Referrals for Chiropractic Care.

    420-J:6-b Self-Referrals for Chiropractic Care. –||A health benefit plan under this chapter offering chiropractic benefits shall provide benefits to a covered person who utilizes services of a chiropractic provider (doctor of chiropractic) by self-referral for 12 visits under the following conditions:||I. Unless otherwise provided for by the health benefits plan, self-referral visits shall not apply to wellness care visits.||II. A covered person may utilize the services of a doctor of chiropractic as defined in RSA 316-A, without discrimination relative to access and fees, subject to the terms and conditions of the policy.||III. The health benefit plan shall fully disclose to the certificate holder in clear and understandable language the exact terms and conditions of each option that the certificate holder has purchased along with the co-payments or other cost-sharing features of each option.||IV. Within 10 working days of the first visit or consultation, the doctor of chiropractic shall send to the health benefit plan, or its designee, the chiropractic case findings. This shall be sufficient documentation for the initial 12 visits.||V. After 12 self-referral visits, a covered person who is continuing chiropractic care may be subject to utilization review from the health plan, or its designee, for the purpose of continued care. A provider of the same specialty shall be consulted when making any utilization review determination under this section.||VI. If the chiropractic provider recommends care beyond 12 visits, the participating doctor of chiropractic shall send to the insurer, or its designee, documentation containing information on the covered person's progress and necessity of care as well as a care plan for extended chiropractic care. The care recommendation shall be deemed authorized if the health benefit plan does not respond to the care recommendation within 7 business days. If the doctor of chiropractic fails to provide the required documentation, the insured or its covered person shall not be liable to the chiropractic provider for any unpaid fees.||VII. The covered person shall retain the right to choose chiropractic care on an elective, self-pay, fee-for-service basis; no entity regulated under this chapter shall prohibit a doctor of chiropractic from continuing care on an elective, self-pay, fee-for-service basis.||VIII. Nothing in this section is intended to limit the health plan's ability to credential providers or structuring with network providers.|||Source. 2000, 14:1, eff. April 18, 2000.|
NH Rev Stat § 420-J:6-c (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:6-c - Third-Party Payment of Covered, Court-Ordered Services.

    420-J:6-c Third-Party Payment of Covered, Court-Ordered Services. –||The existence of a court order under RSA 169-B, RSA 169-C, or RSA 169-D for a service, program, or placement that is covered under any insurance for the minor shall not be considered in determining qualification for third-party payment under such insurance. Benefits for such services shall be subject to the same dollar limits, deductibles, co-payments and co-insurance factors and to the terms and conditions of the policy or certificate, including any managed care provisions. However, the claimant or claimant's representative shall have 48 hours from the commencement of a court-ordered service, placement, or program to seek any pre-authorization, pre-certification, or referral required under the terms of the policy. The determination of these preservice claims for court-ordered services for a minor shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 48 hours after receipt of the request and sufficient information, unless the claimant or claimant's representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable. In the case of such failure, the insurer shall notify the claimant or claimant's representative within 24 hours of receipt of the request and shall advise the claimant or claimant's representative of the specific information necessary to determine to what extent benefits are covered or payable. The claimant or claimant's representative shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. Thereafter, notification of the claim determination shall be made as soon as possible, but in no case later than 48 hours after the earlier of:||I. The insurer's receipt of the specified additional information; or||II. The end of the period afforded the claimant or claimant's representative to provide the specified additional information.|||Source. 2004, 117:4, eff. Aug. 15, 2004.|
NH Rev Stat § 420-J:6-d (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:6-d - Coverage for Dependents.

    420-J:6-d Coverage for Dependents. –||If the coverage for dependent children includes coverage for dependent children who are full-time students, as defined by the appropriate educational institution, beyond the age of 18, such dependent coverage shall include coverage for a dependent's medically necessary leave of absence from school for a period not to exceed 12 months or the date on which coverage would otherwise end pursuant to the terms and conditions of the policy, whichever comes first. Any breaks in the school semester shall not disqualify the dependent child from coverage under this section. Documentation and certification of the medical necessity of a leave of absence shall be submitted to the insurer by the student's attending physician and shall be considered prima facie evidence of entitlement to coverage under this section. The date of the documentation and certification of the medical necessity of a leave of absence shall be the date the insurance coverage under this section commences.|||Source. 2007, 289:29, eff. Jan. 1, 2008.|
NH Rev Stat § 420-J:6-e (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:6-e - Coverage for Medically Necessary Dental Services.

    420-J:6-e Coverage for Medically Necessary Dental Services. –||Health carriers shall provide coverage for medically necessary dental services resulting from an accidental injury to sound natural teeth and gums when the course of treatment for the accidental injury is received or authorized within 3 months of the date of the injury. Treatment made necessary due to injury to the jaw and oral structures other than teeth shall be covered without time limit. Coverage under this section shall be subject to such other terms and conditions of the policy that may apply.|||Source. 2019, 113:3, eff. Aug. 20, 2019.|
NH Rev Stat § 420-J:7 (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:7 - Network Adequacy.

    420-J:7 Network Adequacy. –||I. A health carrier shall maintain a network that is sufficient in numbers, types, and geographic location of providers to ensure that all services to covered persons will be accessible without unreasonable delay.||II. The commissioner shall adopt rules under RSA 541-A for a health carrier's network adequacy. Such rules shall establish, but not be limited to:||(a) Waiting times for appointments for non-emergency care.||(b) Choice of and access to providers for specialty care, specifically addressing the needs of the chronically ill, mentally ill, persons with substance use disorder, developmentally disabled or those with a life threatening illness.||(c) Standards for geographic accessibility, which shall include standards for access to the provision of durable medical equipment requiring a prescription. However, such standards shall not restrict an insurer's ability to provide prescriptions for durable medical equipment that are shipped to the patient by postal service or other common or private carrier, and shall not apply to durable medical equipment devices used exclusively for the administration of medication.||(d) Hours of operation for the carrier, including any entities performing prior approval or pre-authorization functions.||(e) Standards for addressing in-network access to hospital based providers, such as anesthesiologists, radiologists, pathologists, and emergency medicine physicians.||III. The health carrier shall keep, at its place of business, a detailed description of the health carrier's compliance with rules adopted pursuant to RSA 420-J:7, II as well as its procedures for monitoring network adequacy.||IV. Annually, the health carrier shall submit a report to the commissioner demonstrating compliance with the rules for network adequacy.||V. The commissioner shall provide a report annually on the findings associated with network adequacy review to the chairpersons of the house and senate committees having jurisdiction over insurance issues.|||Source. 1997, 345:1. 2008, 311:1, eff. Aug. 31, 2008. 2017, 214:1, eff. Jan. 1, 2018. 2018, 356:3, 4, eff. July 1, 2018.|
NH Rev Stat § 420-J:7-a (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:7-a - Repealed by 2007, 33:2, eff. July 13, 2007.

    420-J:7-a Repealed by 2007, 33:2, eff. July 13, 2007. –|
NH Rev Stat § 420-J:7-c (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:7-c - Disqualification of Certain Physicians Prohibited.

    420-J:7-c Disqualification of Certain Physicians Prohibited. –||A physician who is part of a health carrier's provider network on December 31, 2000, shall not be disqualified from participating in that network solely because such physician is not certified by a member board of the American Board of Medical Specialties.|||Source. 2000, 248:1, eff. Aug. 8, 2000.|
NH Rev Stat § 420-J:7-d (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:7-d - Continued Access to Care Subsequent to a Provider Contract Termination.

    420-J:7-d Continued Access to Care Subsequent to a Provider Contract Termination. –||The commissioner may extend the period of continued access to care subsequent to a provider contract termination provided for under RSA 420-J:8, XI for up to an additional 60-day period.|||Source. 2003, 284:3, eff. July 1, 2003.|
NH Rev Stat § 420-J:7-e (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:7-e - Notice of Consumer Rights.

    420-J:7-e Notice of Consumer Rights. –||A health carrier shall, at least annually, in a conspicuous communication as approved by the commissioner which may be included as an insert in an annual mailing or by electronic communication, notify each covered person of his or her consumer rights under this chapter, including, but not limited to, appeal rights and the ability to access services out-of-network in the event covered services are not available in-network. A health carrier shall also notify covered persons of the right to access out-of-network services when the covered person contacts the health carrier directly requesting assistance finding clinically appropriate in-network care. A health carrier shall also provide notification to covered persons of their right to appeal whenever a covered person contacts the health carrier regarding a denial of coverage or when a health carrier verbally informs the covered person of the denial of coverage.|||Source. 2017, 214:2, eff. Jan. 1, 2018.|
NH Rev Stat § 420-J:8-b (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:8-b - Retroactive Denials Prohibited; Exceptions.

    420-J:8-b Retroactive Denials Prohibited;  Exceptions. –||I. In this section, "retroactive denial of a previously paid claim" means any attempt by a health carrier to retroactively collect payments already made to a health care provider with respect to a claim by requiring repayment of such payments, reducing other payments currently owed to the provider, withholding or setting off against future payments, or reducing or affecting the future claim payments to the provider in any other manner.||II. No health carrier shall impose on any health care provider any retroactive denial of a previously paid claim or any part thereof unless:||(a) The carrier has provided the reason for the retroactive denial in writing to the health care provider; and||(b) The time which has elapsed since the date of payment of the challenged claim does not exceed 12 months. The retroactive denial of a previously paid claim may be permitted beyond 12 months from the date of payment only for the following reasons:||(1) The claim was submitted fraudulently;||(2) The claim payment was incorrect because the provider or the insured was already paid for the health care services identified in the claim;||(3) The health care services identified in the claim were not delivered by the physician/provider;||(4) The claim payment was for services covered by Title XVIII, Title XIX, or Title XXI of the Social Security Act;||(5) The claim payment is the subject of an adjustment with a different insurer, administrator, or payor and such adjustment is not affected by a contractual relationship, association, or affiliation involving claims payment, processing, or pricing; or||(6) The claim payment is the subject of legal action.||III. A health carrier shall notify a health care provider at least 15 days in advance of the imposition of any retroactive denials of previously paid claims. The health care provider shall have 6 months from the date of notification under this paragraph to determine whether the insured has other appropriate insurance, which was in effect on the date of service. Notwithstanding the contractual terms between the health carrier and provider, the health carrier shall allow for the submission of a claim that was previously denied by another insurer due to the insured's transfer or termination of coverage.|||Source. 2002, 143:4. 2006, 104:4, eff. Aug. 7, 2006. 2018, 317:2, eff. Jan. 1, 2019.|
NH Rev Stat § 420-J:8-c (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:8-c - Reimbursement for Providers Waiting for Health Carrier Credentialing Verification.

    420-J:8-c Reimbursement for Providers Waiting for Health Carrier Credentialing Verification. –||I. Pursuant to RSA 420-J:4, I, health carriers issuing health benefit plans subject to this chapter shall pay claims for covered services rendered to covered persons by a health care provider who, at the time of submission of a clean and complete credentialing application, has a valid license from the respective state licensing board and has been credentialed by the hospital, if appropriate. The claim for covered services rendered by the provider applicant shall be paid at the same contracted rate as the credentialed provider:||(a) When covering on-call for another health care provider who is credentialed by the carrier and billed using the name of the credentialed provider; or||(b) Who, at the time of application, is credentialed by the health carrier in another state or is in the health carrier's New Hampshire network based on employment with a particular health care entity.||II. For purposes of RSA 420-J:4 and this section, a health care provider having a valid license shall include all:||(a) Mental health practitioners licensed under RSA 330-A and applicants for mental health practice licensure from other states who are permitted to practice in this state pursuant to RSA 330-A:26, II.||(b) Psychologists licensed under RSA 329-B and psychologists licensed in another jurisdiction issued a temporary license to practice under RSA 329-B:20, III.|||Source. 2007, 98:2, eff. Aug. 10, 2007. 2019, 228:5, eff. Sept. 10, 2019.|
NH Rev Stat § 420-J:8-d (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:8-d - Dependent Coverage.

    420-J:8-d Dependent Coverage. –||I. A policy may, at the election of the carrier, insure, originally or by subsequent amendment, upon application of an adult member of a family who shall be deemed the policyholder, any 2 or more eligible members of that family, including husband, wife, dependent children, or any other person dependent upon the policyholder. In the event a carrier elects to provide coverage for dependent children, the term "dependent child" shall include a subscriber's child by blood or by law, who is under age 26.||I-a. The coverage of any family member insured by such policy, pursuant to paragraph I, who is mentally or physically incapable of earning his or her own living as of the date on which such dependent's status as a covered family member would otherwise expire because of age, shall continue under such policy while such policy remains in force or is replaced by another policy as long as such incapacity continues and as long as such dependent remains chiefly financially dependent on the policyholder or the employee or his or her estate is chargeable for the care of such dependent; provided, that due proof of such incapacity is received by the insurer within 31 days of such expiration date. If such coverage is continued in accordance with this paragraph, such dependent shall be entitled upon the termination of such incapacity to coverage offered by the New Hampshire high risk pool under RSA 404-G.||II. Nothing in this section shall be construed to require:||(a) Coverage for services provided to a dependent before the effective date of this section; or||(b) That an employer pay all or part of the cost of family coverage that includes a dependent as provided pursuant to this section.||III. A subscriber that elects family coverage during any applicable open enrollment period may enroll any dependent eligible pursuant to this section.||IV. Coverage for a dependent provided pursuant to this section shall be provided until the earlier of the following:||(a) The dependent is disqualified for dependent status as set forth in paragraph I of this section;||(b) The date upon which the employer under whose contract coverage is provided to a dependent ceases to provide coverage to the subscriber.||V. Nothing in this section shall be construed to permit a health insurance carrier to refuse an election for coverage by a dependent pursuant to paragraph III, based upon the dependent's prior disqualification pursuant to subparagraph IV(a).||VI. (a) Notice regarding coverage for a dependent as provided pursuant to this section shall be provided to a subscriber:||(1) In the certificate of coverage prepared for subscribers on or about the date of commencement of coverage; and||(2) Within 30 days of the effective date of this section.||(b) Such notice shall include information regarding the required special open enrollment period.|||Source. 2007, 352:6. 2009, 235:18. 2010, 243:13, eff. Sept. 23, 2010.|
NH Rev Stat § 420-J:8-e (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:8-e - Reasonable Value of Health Care Services.

    420-J:8-e Reasonable Value of Health Care Services. –||In the event of a dispute between a health care provider and an insurance carrier relative to the reasonable value of a service under RSA 329:31-b or RSA 415-J:3, the commissioner shall have exclusive jurisdiction to determine if the fee is commercially reasonable. Either the provider or the insurance carrier may petition for a hearing under RSA 400-A:17. The petition shall include the appealing party's evidence and methodology for asserting that the fee is reasonable, and shall detail the efforts made by the parties to resolve the dispute prior to petitioning the commissioner for review. The department may require the parties to engage in mediation prior to rendering a decision.|||Source. 2018, 356:2, eff. July 1, 2018. 2020, 27:35, eff. July 21, 2020.|
NH Rev Stat § 420-J:8-f (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:8-f - Non-Covered Dental Services.

    420-J:8-f Non-Covered Dental Services. –||I. No insurer, health care service contractor, health maintenance organization, dental insurer, or any other similar entity, including Delta Dental Plan of New Hampshire Inc., subject to regulation by the insurance department that covers dental services, and no contract or participating provider agreement with a dentist shall require, directly or indirectly, that a dentist who is a participating provider provide services to an enrolled participant at a fee set by, or at a fee subject to the approval of, the regulated entity unless the dental services are covered services.||II. No person providing third party administrator services shall make available for any customers a plan that sets dental fees for providers in its provider network for any services except covered services.||III. In this paragraph "covered services" means dental care service for which reimbursement is available under an enrollee's plan contract, or for which reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.||IV. Fees for covered services shall be set in good faith and shall not be nominal.|||Source. 2020, 39:14, eff. Jan. 1, 2021.|
NH Rev Stat § 420-J:9 (2021)
2021 New Hampshire Revised Statutes|Title XXXVII - Insurance|Title 420-J - Managed Care Law|Section 420-J:9 - Quality Assessment, Quality Improvement, and Reporting.

    420-J:9 Quality Assessment, Quality Improvement, and Reporting. –||I. A health carrier shall:||(a) Establish and maintain a written quality assessment program designed to collect and evaluate information regarding the quality of the health care processes used by the health carrier and the health outcomes of its covered persons.||(b) Establish and maintain a written quality improvement program structured to identify opportunities to improve care, practices that result in improved health care outcomes, problematic utilization patterns, and those providers who may be responsible for either exemplary or problematic patterns of utilization.||II. The quality improvement program shall at a minimum include: a statement of the objectives of the program; a description of how the health carrier will conduct its quality improvement program; the lines of authority and accountability including data collection responsibilities; evaluation tools; performance improvement activities; and an annual effectiveness review.||III. The chief medical officer or clinical director of the health carrier shall have primary responsibility for the quality assessment and quality improvement activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of this chapter relative to quality assessment and quality improvement are met.||IV. A health carrier shall:||(a) Assure that participating providers have an opportunity to participate in developing, implementing, and evaluating the quality assessment and quality improvement programs.||(b) Maintain at its principal office a copy of the quality assessment program and the quality improvement program which shall be available for inspection by the commissioner or designee at any time during the health carrier's regular business hours.||(c) Certify to the commissioner on or before March 1 of each year that its quality assessment program and its quality improvement program meet the requirements of this chapter and any applicable rules.||(d) Notify the commissioner on or before March 1 of each year of its accreditation by any external accrediting agencies and shall provide a contact person and a phone number for consumer phone calls.|||Source. 1997, 345:1, eff. Jan. 1, 1998.|