reglab/housing_qa huggingface dataset:
SC Code § 38-71-1720 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1720. Definitions.

 As used in this article:  (1) "Closed panel health plan" means a network plan that requires an insured or a member to seek covered health care services or supplies, except in the case of emergency, exclusively from network providers.  (2) "Eligibility" means the time at which an insured or a member is entitled to enroll under the terms of the coverage offered by the network plan by virtue of:  (a) terms of employment;  (b) an annual open enrollment period; or  (c) at any other time during which the network plan's procedures or South Carolina law allows enrollment in the plan or allows renewal in the plan.  (3) "Health insurance coverage" means coverage as defined in Section 38-71-840(14).  (4) "Network plan" means a plan as defined in Section 38-71-840(24).  (5) "Network providers" means those entities and individuals who provide covered health care services or supplies to an insured or a member pursuant to a contract with a network plan to act as a participating provider.  (6) "Open panel health plan" means a plan which permits an insured or a member to seek covered health care services or supplies exclusively from an out-of-network provider.  (7) "Out-of-network providers" means those entities and individuals who provide covered health care services or supplies who are not network providers.  (8) "Point-of-service option" means a network plan that provides benefits for services or supplies provided by network providers and provides benefits for services or supplies provided by nonparticipating network providers.  (a) In-network covered health care services provided through a licensed health maintenance organization are governed by and subject to the provisions of Chapter 33 of this title.  (b) Out-of-network coverage may be underwritten by and provided through the health maintenance organization or through a licensed insurance company. The Director of Insurance may promulgate regulations as necessary or appropriate to implement the provisions of this subsection.  (c) Any benefit limitation for out-of-network covered health care services applied to an annual or lifetime benefit limitation may be offset against the benefit limitation applicable to in-network covered health care services or supplies, regardless of whether out-of-network coverage is provided through a health maintenance organization or an insurance company.  (d) The rating methods used to establish premiums for the point-of-service option must be based on actuarially sound principles.  HISTORY: 1998 Act No. 441, Section 1.
SC Code § 38-71-1740 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1740. Responsibility for errors and omissions by parties to managed care participating provider agreements; limitations on network providers to discuss treatments, risks and legal obligations with an insured or member prohibited; permissible limitations.

 (A) For purposes of any health insurance plan, health maintenance organization, or any other health benefits plan offered in this State under the jurisdiction of South Carolina law:  (1) Each party to a managed care participating provider agreement is responsible for the legal consequences and costs of his own acts or omissions, or both, and is not responsible for the acts or omissions, or both, of the other party. A clause in a participating provider agreement to the contrary is unlawful in this State, as a matter of public policy, whether entered into before or after January 1, 1999.  (2) To the extent that a network plan requires an insured or a member to receive health benefits through a network of providers, the provisions of participating provider agreements may not limit the network provider's:  (a) ability to discuss with an insured or a member, the treatment options available to the insured or member, risks associated with treatments, utilization management decisions, and recommended course of treatment;  (b) legal obligations to an insured or a member as specified under the provider's professional license.  (B) Nothing in this section:  (1) prevents a network plan from prohibiting disclosure by network providers of trade secrets;  (2) subjects a network plan to liability for clinical decisions made solely by the network provider; and  (3) limits the ability of the network plan otherwise prudently to administer its provider contracts.  HISTORY: 1998 Act No. 441, Section 1.
SC Code § 38-71-1750 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1750. Disclosures required of network plans.

 A network plan must disclose in writing, using the plain and ordinary meaning of words so as reasonably to ensure comprehension by the insured or member, and make available to an insured or a member at the time of enrollment:  (1) services or benefits under the plan, including limitations on services;  (2) rules regarding copayments, prior authorization, and review requirements that apply to the benefits plan of the insured or member;  (3) potential financial liability for the insured or member to pay for a portion of services received from an out-of-network provider;  (4) financial obligations of the insured or member for items and services both in and out of the network;  (5) the number, mix, and distribution of network providers and a current list of network providers upon request from an insured or a member;  (6) the rights and responsibilities of an insured or a member, including an explanation of any appeals process for the denial of care or services under the plan;  (7) the existence of any limitations on the choice of providers by an insured or a member.  HISTORY: 1998 Act No. 441, Section 1.
SC Code § 38-71-1760 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1760. Promulgation of regulations.

 The Director of the Department of Insurance or his designee shall promulgate regulations to implement the provisions of this chapter.  HISTORY: 2000 Act No. 312, Section 16.
SC Code § 38-71-1820 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1820. Appeals process; dismissal; copy of audit findings.

 (A) Each entity that conducts an audit of a pharmacy shall establish an appeals process under which a pharmacy may appeal an unfavorable preliminary audit report to the entity.  (B) If, following the appeal, the entity finds that an unfavorable audit report or any portion of the unfavorable audit report is unsubstantiated, the entity shall dismiss the unsubstantiated portion of the audit report without any further proceedings.  (C) Each entity conducting an audit shall provide a copy, if required under the terms of the contract with the responsible party, of the audit findings to the plan sponsor after completion of any appeals process.  HISTORY: 2012 Act No. 250, Section 1, eff January 1, 2013.
SC Code § 38-71-1830 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1830. Recoupment.

 (A) Recoupments of any funds disputed on the basis of an audit must occur only after final internal disposition of the audit, including the appeals process as provided for in Section 38-71-1820, unless fraud or misrepresentation is reasonably suspected.  (B) Recoupment on an audit must be refunded to the responsible party as contractually agreed upon by the parties involved in the audit.  (C) The entity conducting the audit may charge or assess the responsible party, directly or indirectly, based on amounts recouped if both of the following conditions are met:  (1) the responsible party or payor and the entity conducting the audit have entered into a contract that explicitly states the percentage charge or assessment to the responsible party; and  (2) a commission or other payment to an agent or employee of the entity conducting the audit is not based, directly or indirectly, on amounts recouped.  HISTORY: 2012 Act No. 250, Section 1, eff January 1, 2013.
SC Code § 38-71-1840 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1840. Exemptions.

 The provisions of this article do not apply to an audit, review, or investigation:  (1) that involves alleged insurance fraud or abuse, Medicare fraud or abuse, or other fraud or misrepresentation; or  (2) conducted by or on the behalf of the Department of Health and Human Services in the performance of its duties in administering Medicaid under Titles XIX and XXI of the Social Security Act.  HISTORY: 2012 Act No. 250, Section 1, eff January 1, 2013.
SC Code § 38-71-1910 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1910. Short title.

 This article may be cited as the "Health Carrier External Review Act".  HISTORY: 2000 Act No. 380, Section 3A.
SC Code § 38-71-1930 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1930. Application of this article.

 (A) Except as provided in subsection (B), this article applies to all health carriers that provide or perform utilization review, including those plans subject to regulation under Chapter 33.  (B) This article does not apply to the administrative services performed on behalf of a self-funded plan subject to the Employee Retirement Income Security Act (ERISA) of 1974.  (C) For purposes of this article, notice to the subscriber or insured entitled to covered benefits under a health benefit plan shall constitute notice to the covered person. This subsection does not affect the health plan's obligations under a court order requiring a parent to provide health coverage pursuant to Section 63-17-2100, et seq.  HISTORY: 2000 Act No. 380, Section 3A.
SC Code § 38-71-1940 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1940. Notice of right to request a review; notice of adverse determination.

 (A) A health carrier shall notify the covered person in writing of the right to request an external review and include the appropriate statements and information set forth in subsection (B) at the time the health carrier sends written notice of either an adverse determination or a final adverse determination.  (B)(1) The health carrier shall include in the notice required under subsection (A) a clear and concise description of the right of the covered person to request a standard external review pursuant to Section 38-71-1970 or an expedited external review pursuant to Section 38-71-1980 upon receipt of an adverse determination or a final adverse determination and the circumstances under which the covered person is not required to exhaust the health carrier's internal appeal process or is considered to have exhausted the health carrier's internal appeal process pursuant to Section 38-71-1960.  (2) In addition to the information to be provided pursuant to item (1), the health carrier shall include a brief description of both the standard and expedited external review procedures.  (3) As part of any forms provided under item (2), the health carrier shall include an authorization form, or other document promulgated or approved by the director or his designee, by which the covered person, for purposes of conducting an external review under this article, authorizes the health carrier to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review.  (C) A notice, statement, or form required by this section must achieve a score of no lower than 70 on the Flesch Reading East Test and must be printed in no smaller than 12 point type. No part of the notice, statement, or form may be printed in all capitals. A notice, statement, or form required by this section must include a statement of the right of the covered person to contact the director or his designee for assistance. The statement must include the telephone number and address of the director or his designee.  (D) A notice, statement, or form required by this section must be approved by the Department of Insurance. The director or his designee shall promulgate standard language, in a specified font size and type for any notice, statement, or form required by this section. Use of the standard language in the specified font size and type promulgated by the department pursuant to this section shall constitute compliance with the notice requirements of this section.  HISTORY: 2000 Act No. 380, Section 3A.
SC Code § 38-71-1950 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1950. Requests for external review.

 (A) All requests for external review must be made in writing to the health carrier.  (B) A covered person or his authorized representative may make a request for an external review of an adverse determination or final adverse determination only when the amount payable for covered benefits is at least five hundred dollars.  (C) A covered person is not entitled to an external review of a retrospective review determination unless the covered person has exhausted the health carrier's internal appeal process and may be held financially responsible for the covered benefits.  HISTORY: 2000 Act No. 380, Section 3A.
SC Code § 38-71-1960 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1960. Exhaustion of internal appeal process.

 (A)(1) Except in cases where the covered person's treating physician has certified in writing that the covered person has a serious medical condition, or where the denial of coverage is based on a determination that the health care service or treatment recommended or requested is experimental or investigational and the covered person's treating physician has provided the certifications required pursuant to Section 38-71-1980, a request for a standard or expedited external review may not be made until the covered person has exhausted the health carrier's internal appeal process.  (2) A covered person is considered to have exhausted the health carrier's internal appeal process for purposes of this section, if the covered person or his authorized representative:  (a) has filed an appeal involving an adverse determination pursuant to the health carrier's internal appeal process; and  (b) the health carrier has not issued a written decision within the time frames set forth in the health carrier's internal appeals process after receipt of all information necessary to complete the appeal and the covered person or his authorized representative has not agreed to a delay.  (B) A request for an external review of an adverse determination may be made before the covered person has exhausted the health carrier's internal appeal process whenever the health carrier agrees to waive the exhaustion requirement.  (C) If the requirement to exhaust the health carrier's internal appeal process is waived under subsection (B), the covered person or his authorized representative may file a request in writing for an external review.  HISTORY: 2000 Act No. 380, Section 3A.
SC Code § 38-71-1990 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-1990. External review decisions final; exceptions.

 (A) An external review decision is binding on the health carrier.  (B) An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or state law. If such other remedies are available, the covered person or his authorized representative may not, in these proceedings, utilize, disclose, or introduce in evidence information generated during or findings reached by the independent review organization.  (C) A covered person or his authorized representative may not file a subsequent request for external review involving the same adverse determination or final adverse determination.  HISTORY: 2000 Act No. 380, Section 3A.
SC Code § 38-71-2020 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-2020. Liability of independent review organizations and personnel.

 No independent review organization, or employee, officer, or director of an independent review organization or health care professional who furnishes services to an independent review organization is liable to any person for any acts or omissions arising out of or related to an external review conducted pursuant to this article, except for cases of wilful and intentional misconduct.  HISTORY: 2000 Act No. 380, Section 3A.
SC Code § 38-71-2030 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-2030. External review; written records; reports.

 (A)(1) An independent review organization assigned pursuant to Section 38-71-1970 or Section 38-71-1980 to conduct an external review shall maintain written records in the aggregate and by health carrier on all requests for external review for which it conducted an external review during a calendar year and submit a report to the director or his designee, as required under item (2).  (2) Each independent review organization required to maintain written records on all requests for external review pursuant to item (1) for which it was assigned to conduct an external review shall submit to the director or his designee, no later than March first of each year and upon request by the director or his designee, a report in the format specified by the director or his designee.  (3) The report shall include in the aggregate and for each health carrier:  (a) the total number of requests for external review and the manner in which they were resolved;  (b) the average length of time for resolution;  (c) a summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the director or his designee; and  (d) any other information the director or his designee may request or require.  (4) The independent review organization shall retain the written records required pursuant to this subsection for at least three years.  (B)(1) Each health carrier shall maintain written records in the aggregate and for each general type of health benefit plan offered by the health carrier on all requests for external review that are filed with the health carrier during a calendar year.  (2) Each health carrier required to maintain written records on all requests for external review pursuant to item (1) shall submit to the director or his designee, no later than March first of each year and upon request by the director or his designee, a report in the format specified by the director or his designee.  (3) The report shall include in the aggregate and by type of health benefit plan:  (a) the total number of requests for external review and the manner in which they were resolved;  (b) the average length of time for resolution;  (c) a summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the director or his designee; and  (d) any other information the director or his designee may request or require.  (4) The health carrier shall retain the written records required pursuant to this subsection for at least three years.  (C) The director or his designee shall make the reports required in this section available to any person for inspection and copying upon request.  HISTORY: 2000 Act No. 380, Section 3A.
SC Code § 38-71-2040 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-2040. Health carrier to pay for external review.

 The health carrier shall pay for the external review.  HISTORY: 2000 Act No. 380, Section 3A.
SC Code § 38-71-2050 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-2050. Health carrier to inform covered persons of rights related to external review.

 (A) Each health carrier shall include a description of the external review procedures in either the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to covered persons.  (B) The description required under subsection (A) shall include a statement of the right of the covered person to contact the director or his designee for assistance. The statement shall include the telephone number and address of the director or his designee.  (C) In addition to subsection (B), the statement shall inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.  HISTORY: 2000 Act No. 380, Section 3A.
SC Code § 38-71-2060 (2021)
2021 South Carolina Code of Laws|Title 38 - Insurance|Chapter 71 - Accident And Health Insurance|Section 38-71-2060. Regulations.

 The director or his designee may, after notice, promulgate reasonable regulations or bulletins to carry out the provisions of this article.  HISTORY: 2000 Act No. 380, Section 3A.