reglab/housing_qa huggingface dataset:
18 DE Code § 3370B. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter I. General Provisions|§ 3370B. Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome.

§ 3370B. Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome. (a) All individual health insurance policies, contracts, or certificates that are delivered, issued for delivery, renewed, extended, or modified in this State by any health insurer, health service corporation, or health maintenance organization shall provide coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome, including the use of intravenous immunoglobulin therapy. (b) At any time that the State is required by the Secretary of the United States Department of Health and Human Services, or its successor agency, to defray the cost of any coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome required under subsection (a) of this section, the requirements under subsection (a) of this section are inoperative and the State may not assume any obligation for the cost of coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome. 81 Del. Laws, c. 400, § 1;
18 DE Code § 3370C. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter I. General Provisions|§ 3370C. Time of submitting claim for reimbursement.

§ 3370C. Time of submitting claim for reimbursement. (a) For purposes of this section:  (1) “Carrier” means any entity that provides health insurance in this State. “Carrier” includes an insurance company, health service corporation, health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. “Carrier” also includes any third-party administrator or other entity that adjusts, administers, or settles claims in connection with health benefit plans.  (2) “Carrier” does not mean an entity that provides a plan of health insurance or health benefits designed for issuance to persons eligible for coverage under Titles XVIII, XIX, and XXI of the Social Security Act (42 U.S.C. §§ 1395 et seq., 1396 et seq. and 1397 et seq.), known as Medicare, Medicaid, or any other similar coverage under state or federal governmental plans.  (b) Regardless of network status, a carrier shall permit a provider a minimum of 180 days from the date a covered service is rendered to submit a claim for reimbursement. Any contract between a carrier and provider that prohibits a provider from submitting a claim beyond the minimum time limit required under this section shall not be deemed a violation of this section. 82 Del. Laws, c. 111, § 3;
18 DE Code § 3370D. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter I. General Provisions|§ 3370D. Coverage for epinephrine autoinjectors.

§ 3370D. Coverage for epinephrine autoinjectors. (a) For purposes of this section, “epinephrine autoinjector” means a single-use device used for the automatic injection of a premeasured dose of epinephrine into the human body.  (b) All individual health insurance policies, contracts, or certificates that are delivered, issued for delivery, renewed, extended, or modified in this State shall provide coverage for medically-necessary epinephrine autoinjectors for individuals who are 18 years of age or under by including at least 1 formulation of epinephrine autoinjectors on the lowest tier of the drug formulary developed and maintained by the carrier. (c) Nothing in this section prevents the operation of a policy provision required by this section as a deductible, coinsurance, allowable charge limitation, coordination of benefits, or a provision restricting coverage to services by a licensed, certified, or carrier-approved provider or facility. (d) This section applies to all policies, contracts, or certificates issued, renewed, modified, altered, amended, or reissued after December 31, 2021. (e) This section does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement long-term care, disability income, or other limited benefit health insurance policies. 83 Del. Laws, c. 42, § 1;
18 DE Code § 3372 (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter II. Pre-Authorization Transparency|§ 3372. requirements.

§ 3372 Disclosure and review of pre-authorization requirements. (a) A utilization review entity shall make any current pre-authorization requirements and restrictions readily accessible on its website and in written or electronic form upon request for covered persons, health-care providers, and others with access to the website. Information from a utilization review entity that is not an insurer, health-benefit plan, or health-service corporation shall make this information available at an electronic pre-authorization portal that is accessible in real time. Requirements shall be described in detail but also in clear, easily-understandable language. Clinical criteria shall be described in language easily understandable by a health-care provider practicing in the same clinical area. (b) If an insurer, health-benefit plan, or health-service corporation intends either to implement a new pre-authorization requirement or restriction, or amend an existing requirement or restriction, they shall ensure that the new or amended requirement is not implemented unless their website has been updated to reflect the new or amended requirement or restriction. This shall not extend to expansion of coverage for new health-care services. (c) If an insurer, health-benefit plan, or health-service corporation intends either to implement a new pre-authorization requirement or restriction, or amend an existing requirement or restriction, they shall provide covered persons who are currently authorized by the utilization review entity for coverage of the affected health-care service and all contracted health-care providers who provide affected health-care service or services of written notice of the new or amended requirement or amendment no less than 60 days before the requirement or restriction is implemented. Such notice may be delivered electronically or by other means. (d) Insurers, health-benefit plans, and health-service corporations utilizing pre-authorization shall report de-identified statistics regarding pre-authorization approvals, denials, and appeals to the Delaware Health Information Network in a format and frequency, no less than twice annually, of the Delaware Health Information Network's request. The Department may also request this data at any time. The statistics shall include, but may be expanded upon or further delineated by regulation, categories for all of the following:  (1) For denials, the aggregated reasons for denials such as, but not limited to, medical necessity or incomplete pre-authorization submission. (2) For appeals:  a. Practitioner specialty;  b. Medication, diagnostic test, or diagnostic procedure;  c. Indication offered; d. Reason for underlying denial; and e. Number of denials overturned upon appeal.80 Del. Laws, c. 310, § 1;
18 DE Code § 3373. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter II. Pre-Authorization Transparency|§ 3373. Utilization review entity's obligations with respect to pre-authorizations in nonemergency circumstances.

§ 3373. Utilization review entity's obligations with respect to pre-authorizations in nonemergency circumstances. (a) If a utilization review entity requires pre-authorization of a pharmaceutical, the utilization review entity must complete its process or render an adverse determination and notify the covered person's health-care provider within 2 business days of obtaining a clean pre-authorization or of using services described in § 3377 of this title. (b) If a utilization review entity requires pre-authorization of a health-care service, the utilization review entity must grant a pre-authorization or issue an adverse determination and notify the covered person's health-care provider of the determination within 8 business days of receipt of a clean pre-authorization not submitted through electronic pre-authorization. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required. (c) If a utilization review entity requires pre-authorization of a health-care service, the utilization review entity must grant a pre-authorization or issue an adverse determination and notify the covered person's health-care provider of the determination within 5 business days of receipt of a clean pre-authorization through electronic pre-authorization. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required. 80 Del. Laws, c. 310, § 1;
18 DE Code § 3374. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter II. Pre-Authorization Transparency|§ 3374. Utilization review entity's obligations with respect to pre-authorization concerning emergency health-care services.

§ 3374. Utilization review entity's obligations with respect to pre-authorization concerning emergency health-care services. A utilization review entity must follow all emergency procedures and mandates as delineated in §§ 3349 and 3565 of this title. 80 Del. Laws, c. 310, § 1;
18 DE Code § 3375. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter II. Pre-Authorization Transparency|§ 3375. Retrospective denial.

§ 3375. Retrospective denial. The utilization review entity may not revoke, limit, condition or restrict a pre-authorization on ground of medical necessity after the date the health-care provider received the pre-authorization. Any language attempting to disclaim payment for services on the basis of changes to medical necessity that have been pre-authorized and delivered while under coverage shall be null and void. A proper notification of policy changes validly delivered as per § 3372 of this title may void a pre-authorization if received after pre-authorization but before delivery of the service. 80 Del. Laws, c. 310, § 1;
18 DE Code § 3376. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter II. Pre-Authorization Transparency|§ 3376. Length of pre-authorization.

§ 3376. Length of pre-authorization. (a) A pre-authorization for pharmaceuticals shall be valid for 1 year from the date the health-care provider receives the pre-authorization, subject to confirmation of continued coverage and eligibility and to policy changes validly delivered as per § 3372 of this title and except as otherwise set by evidence-based treatment protocol. (b) A pre-authorization for a health-care service shall be valid for a period of time that is reasonable and customary for the specific service, but no less than 60 days, from the date the health-care provider receives the pre-authorization, subject to confirmation of continued coverage and eligibility and to policy changes validly delivered as per § 3372 of this title. 80 Del. Laws, c. 310, § 1;
18 DE Code § 3377. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter II. Pre-Authorization Transparency|§ 3377. Electronic standards for pharmaceutical pre-authorization.

§ 3377. Electronic standards for pharmaceutical pre-authorization. No later than January 1, 2018, the insurer must accept and respond to pre-authorization requests under the pharmacy benefit through a secure electronic transmission using the NCPDP SCRIPT standard ePA transactions. Facsimile, proprietary payer portals, and electronic forms shall not be considered electronic transmission.  80 Del. Laws, c. 310, § 1;
18 DE Code § 3378. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter II. Pre-Authorization Transparency|§ 3378. Health-care services deemed preauthorized if a utilization review entity fails to comply with the requirements of this subchapter.

§ 3378. Health-care services deemed preauthorized if a utilization review entity fails to comply with the requirements of this subchapter. Any failure by a utilization review entity to comply with the deadlines and other requirements specified in this subchapter will result in any health-care services subject to review to be automatically deemed preauthorized.  80 Del. Laws, c. 310, § 1;
18 DE Code § 3379. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter II. Pre-Authorization Transparency|§ 3379. Waiver prohibited.

§ 3379. Waiver prohibited. The provisions of this subchapter cannot be waived by contract issued or renewed after January 1, 2017. Any contractual arrangement in conflict with the provisions of this subchapter or that purports to waive any requirements of this subchapter is null and void. 80 Del. Laws, c. 310, § 1;
18 DE Code § 3380. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33. Health Insurance Contracts|Subchapter II. Pre-Authorization Transparency|§ 3380. Exemptions.

§ 3380. Exemptions. This subchapter shall not apply to policies or contracts designed for issuance to persons eligible for coverage under Titles XVIII, XIX, and XXI of the Social Security Act [42 U.S.C. § 1395 et seq., § 1396 et seq. and § 1397aa. et seq.], known as Medicare, Medicaid, or any other similar coverage under state or federal governmental plans. 80 Del. Laws, c. 310, § 1;
18 DE Code § 3301A. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33A. Pharmacy Benefits Managers [For Application of This Chapter, See 80 Del. Laws, C. 245, §? 2]|Subchapter I. Pharmacy Audit Integrity Program [For Application of This Subchapter, See 80 Del. Laws, C. 245, § 2]|§ 3301A. Pharmacy Audit Integrity Program [For application of this section, see 80 Del. Laws, c. 245, § 2].

§ 3301A. Pharmacy Audit Integrity Program [For application of this section, see 80 Del. Laws, c. 245, § 2]. The Pharmacy Audit Integrity Program is established to provide standards for an audit of pharmacy records carried out by a pharmacy benefits manager or any entity that represents pharmacy benefits managers. 80 Del. Laws, c. 65, §  1;  80 Del. Laws, c. 245, § 1;
18 DE Code § 3302A. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33A. Pharmacy Benefits Managers [For Application of This Chapter, See 80 Del. Laws, C. 245, §? 2]|Subchapter I. Pharmacy Audit Integrity Program [For Application of This Subchapter, See 80 Del. Laws, C. 245, § 2]|§ 3302A. Definitions [For application of this section, see 80 Del. Laws, c. 245, § 2; and 83 Del. Laws, c. 256, § 15].

§ 3302A. Definitions [For application of this section, see 80 Del. Laws, c. 245, § 2; and 83 Del. Laws, c. 256, § 15]. For purposes of this subchapter:  (1) “Entity” means a pharmacy benefits manager or any person or organization that represents these companies, groups, or organizations. (2) “Pharmacy benefits manager” or “PBM” means an entity that contracts with pharmacists or pharmacies on behalf of a person to do any of the following:  a. Process claims for prescription drugs or medical supplies or provide retail network management for pharmacies or pharmacists. b. Pay pharmacies or pharmacists for prescription drugs or medical supplies. c. Negotiate rebates with manufacturers for drugs paid for or procured as described in this chapter. (3) “Plan sponsor” means as defined under § 4405 of this title.80 Del. Laws, c. 65, §  1;  80 Del. Laws, c. 245, § 1;  83 Del. Laws, c. 256, § 1;
18 DE Code § 3303A. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33A. Pharmacy Benefits Managers [For Application of This Chapter, See 80 Del. Laws, C. 245, §? 2]|Subchapter I. Pharmacy Audit Integrity Program [For Application of This Subchapter, See 80 Del. Laws, C. 245, § 2]|§ 3303A. Pharmacy benefit manager contract [For application of this section, see 80 Del. Laws, c. 245, §  2].

§ 3303A. Pharmacy benefit manager contract [For application of this section, see 80 Del. Laws, c. 245, §  2]. An amendment to pharmacy audit terms in a contract between a PBM and a pharmacy must be disclosed to the pharmacy at least 60 days prior to the effective date of the proposed change. 80 Del. Laws, c. 65, §  1;  80 Del. Laws, c. 245, § 1;
18 DE Code § 3305A. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33A. Pharmacy Benefits Managers [For Application of This Chapter, See 80 Del. Laws, C. 245, §? 2]|Subchapter I. Pharmacy Audit Integrity Program [For Application of This Subchapter, See 80 Del. Laws, C. 245, § 2]|§ 3305A. Requirements for recoupment or chargeback [For application of this section, see 80 Del. Laws, c. 245, §  2].

§ 3305A. Requirements for recoupment or chargeback [For application of this section, see 80 Del. Laws, c. 245, §  2]. For recoupment or chargeback, the following criteria apply:  (1) Audit parameters must consider consumer-oriented parameters based on manufacturer listings. (2) The reimbursable cost for a compounded medication shall be reflective of the ingredients, supplies and professional time reasonably required to create the finished product. (3) A finding of overpayment or underpayment must be based on the actual overpayment or underpayment and not a projection based on the number of patients served having a similar diagnosis or on the number of similar orders or refills for similar drugs. (4) The entity conducting the audit shall not use extrapolation in calculating the recoupment or penalties for audits unless required by state or federal law or regulations. (5) Calculations of overpayments must not include dispensing fees unless a prescription was not actually dispensed, the prescriber denied authorization, the prescription dispensed was a medication error by the pharmacy, or the identified overpayment is solely based on an extra dispensing fee. (6) An entity may not consider any clerical or record-keeping error, such as a typographical error, scrivener's error, or computer error regarding a required document or record as fraud, however such errors may be subject to recoupment. (7) In the case of errors that have no actual financial harm to the patient or plan, the PBM must not assess any chargebacks. Errors that are a result of the pharmacy failing to comply with a formal corrective action plan may be subject to recovery. (8) Interest may not accrue during the audit period for either party, beginning with the notice of the audit and ending with the final audit report.80 Del. Laws, c. 65, §  1;  80 Del. Laws, c. 245, § 1;
18 DE Code § 3306A. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33A. Pharmacy Benefits Managers [For Application of This Chapter, See 80 Del. Laws, C. 245, §? 2]|Subchapter I. Pharmacy Audit Integrity Program [For Application of This Subchapter, See 80 Del. Laws, C. 245, § 2]|§ 3306A. Documentation [For application of this section, see 80 Del. Laws, c. 245, §  2].

§ 3306A. Documentation [For application of this section, see 80 Del. Laws, c. 245, §  2]. (a) To validate the pharmacy record and delivery, the pharmacy may use authentic and verifiable statements or records including medication administration records of a nursing home, assisted living facility, hospital, physician, or other authorized practitioner or additional audit documentation parameters located in the provider manual. (b) Any legal prescription that meets the requirements in this subchapter may be used to validate claims in connection with prescriptions, refills, or changes in prescriptions, including medication administration records, faxes, e-prescriptions, or documented telephone calls from the prescriber or the prescriber's agents. 80 Del. Laws, c. 65, §  1;  80 Del. Laws, c. 245, § 1;
18 DE Code § 3307A. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33A. Pharmacy Benefits Managers [For Application of This Chapter, See 80 Del. Laws, C. 245, §? 2]|Subchapter I. Pharmacy Audit Integrity Program [For Application of This Subchapter, See 80 Del. Laws, C. 245, § 2]|§ 3307A. Appeals process [For application of this section, see 80 Del. Laws, c. 245, §  2].

§ 3307A. Appeals process [For application of this section, see 80 Del. Laws, c. 245, §  2]. The entity conducting the audit must establish a written appeals process which must include appeals of preliminary reports and final reports. 80 Del. Laws, c. 65, §  1;  80 Del. Laws, c. 245, § 1;
18 DE Code § 3308A. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33A. Pharmacy Benefits Managers [For Application of This Chapter, See 80 Del. Laws, C. 245, §? 2]|Subchapter I. Pharmacy Audit Integrity Program [For Application of This Subchapter, See 80 Del. Laws, C. 245, § 2]|§ 3308A. Audit information and reports [For application of this section, see 80 Del. Laws, c. 245, §  2].

§ 3308A. Audit information and reports [For application of this section, see 80 Del. Laws, c. 245, §  2]. (a) A preliminary audit report must be delivered to the pharmacy within 30 days after the conclusion of the audit. The preliminary audit report shall contain claim level information for any discrepancy and an estimated recovery amount. (b) A pharmacy must be allowed at least 45 days following receipt of the preliminary audit to provide documentation to address any discrepancy found in the audit. (c) A final audit report must be delivered to the pharmacy within 120 days after receipt of the preliminary audit report or final appeal, whichever is later. (d) An entity shall remit any money due to a pharmacy or pharmacist as a result of an underpayment of a claim within 45 days after the appeals process has been exhausted and the final audit report has been issued. 80 Del. Laws, c. 65, §  1;  80 Del. Laws, c. 245, § 1;
18 DE Code § 3309A. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33A. Pharmacy Benefits Managers [For Application of This Chapter, See 80 Del. Laws, C. 245, §? 2]|Subchapter I. Pharmacy Audit Integrity Program [For Application of This Subchapter, See 80 Del. Laws, C. 245, § 2]|§ 3309A. Disclosures to plan sponsor [For application of this section, see 80 Del. Laws, c. 245, §  2].

§ 3309A. Disclosures to plan sponsor [For application of this section, see 80 Del. Laws, c. 245, §  2]. Where contractually required, an auditing entity must provide a copy to the plan sponsor of its claims that were included in the audit, and any recouped money shall be returned to the plan sponsor. 80 Del. Laws, c. 65, §  1;  80 Del. Laws, c. 245, § 1;
18 DE Code § 3310A. (2021)
2021 Delaware Code|Title 18 - Insurance Code|Chapter 33A. Pharmacy Benefits Managers [For Application of This Chapter, See 80 Del. Laws, C. 245, §? 2]|Subchapter I. Pharmacy Audit Integrity Program [For Application of This Subchapter, See 80 Del. Laws, C. 245, § 2]|§ 3310A. Applicability of other laws and regulations [For application of this section, see 80 Del. Laws, c. 245, § 2].

§ 3310A. Applicability of other laws and regulations [For application of this section, see 80 Del. Laws, c. 245, § 2]. This subchapter does not apply to any investigative audit that involves suspected fraud, wilful misrepresentation, abuse, or any audit completed by the State. 80 Del. Laws, c. 65, §  1;  80 Del. Laws, c. 245, § 1;