reglab/statecodes huggingface dataset:
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1318 - Powers of mutual holding company, engaging in business of insurance, no authority, affiliation and merger agreements.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 1996
376.1318. Powers of mutual holding company, engaging in business of insurance, no authority, affiliation and merger agreements. —
A mutual holding company shall have the same powers granted to domestic insurance companies pursuant to chapter 382 relating to insurance holding company systems, and shall be subject to the requirements and provisions of such chapter and shall have all the powers granted to corporations organized pursuant to chapter 351. Neither the mutual holding company nor any stock holding company created pursuant to sections 376.1300 to 376.1322 shall be an insurer or shall have the authority to engage in the business of insurance. A mutual holding company may enter into an affiliation agreement or a merger agreement either at the time of reorganization, or at some later time with the approval of the director, with any mutual life insurance company authorized to do business in this state. Any such merger agreement may authorize participating policyholders of the mutual life insurance company to become members of the mutual holding company. Any such affiliation agreement or merger agreement is subject to the insurance laws of this state relating to such transactions entered into by a domestic mutual life insurance company.
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(L. 1996 S.B. 759)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1322 - Mutual holding company subject to supervision of director, dissolution or liquidation — demutualization.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 1996
376.1322. Mutual holding company subject to supervision of director, dissolution or liquidation — demutualization. —
1. A mutual holding company is subject to the supervision of the director of the department of commerce and insurance in the same manner as an insurer subject to the provisions of this chapter and shall automatically be a party to any proceeding pursuant to the Missouri insurers supervision, rehabilitation and liquidation act, sections 375.1150 to 375.1246, involving a life insurance company which, as a result of a reorganization pursuant to section 376.1300, is a subsidiary of the mutual holding company or a stock holding company created pursuant to section 376.1307. In any proceeding pursuant to sections 375.1150 to 375.1246 involving the reorganized life insurance company, the assets of the mutual holding company are deemed to be assets of the estate of the reorganized life insurance company for purposes of satisfying the claims of the reorganized life insurance company's policyholders. A mutual holding company shall not dissolve or liquidate without the approval of the director of the department of commerce and insurance or as ordered by the court pursuant to sections 375.1150 to 375.1246.
2. Sections 375.201 to 375.226 shall apply to a demutualization of a mutual holding company the same as if such holding company was a mutual life insurance company. This section does not apply to those companies organized under chapter 354 or chapter 355 and does apply only to for-profit mutual life insurance companies.
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(L. 1996 S.B. 759)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1345 - Method of reimbursement not to require fee, discount, or remuneration — notification requirements — electronic funds transfer, when — overpayment, procedure — violation, penalty.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
Effective - 28 Aug 2020, 2 histories
376.1345. Method of reimbursement not to require fee, discount, or remuneration — notification requirements — electronic funds transfer, when — overpayment, procedure — violation, penalty. —
1. As used in this section, unless the context clearly indicates otherwise, terms shall have the same meaning as ascribed to them in section 376.1350.
2. No health carrier, nor any entity acting on behalf of a health carrier, shall restrict methods of reimbursement to health care providers for health care services to a reimbursement method requiring the provider to pay a fee, discount the amount of their claim for reimbursement, or remit any other form of remuneration in order to redeem the amount of their claim for reimbursement.
3. If a health carrier initiates or changes the method used to reimburse a health care provider to a method of reimbursement that will require the health care provider to pay a fee, discount the amount of its claim for reimbursement, or remit any other form of remuneration to the health carrier or any entity acting on behalf of the health carrier in order to redeem the amount of its claim for reimbursement, the health carrier or an entity acting on its behalf shall:
(1) Notify such health care provider of the fee, discount, or other remuneration required to receive reimbursement through the new or different reimbursement method; and
(2) In such notice, provide clear instructions to the health care provider as to how to select an alternative payment method, and upon request such alternative payment method shall be used to reimburse the provider until the provider requests otherwise.
4. A health carrier shall allow the provider to select to be reimbursed by an electronic funds transfer through the Automated Clearing House Network as required pursuant to 45 C.F.R. Sections 162.925, 162.1601, and 162.1602, and if the provider makes such selection, the health carrier shall use such reimbursement method to reimburse the provider until the provider requests otherwise.
5. An amount a health carrier claims was overpaid to a provider may only be collected, withheld, or recouped from the provider, or third party that submitted the provider's claim under the third party's provider identification number, to whom the overpaid amount was originally paid. The notice of withholding or recoupment by a health carrier shall also inform the provider or third party of the health care service, date of service, and patient for which the recoupment is being made.
6. Violation of this section shall be deemed an unfair trade practice under sections 375.930 to 375.948.
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(L. 2019 S.B. 514, A.L. 2020 H.B. 1682)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1353 - Utilization review activities monitored.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 1997
376.1353. Utilization review activities monitored. —
A health carrier shall be responsible for monitoring all utilization review activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of sections 376.1350 to 376.1390 and applicable rules and regulations are met. The health carrier shall also ensure that appropriate personnel have operational responsibility for the conduct of the health carrier's utilization review program.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1356 - Utilization review entity monitored, when.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2019, 2 histories
376.1356. Utilization review entity monitored, when. —
Whenever a health carrier contracts to have a utilization review entity perform the utilization review functions required by sections 376.1350 to 376.1390
*
or applicable rules and regulations, the health carrier shall be responsible for monitoring the activities of the utilization review entity with which the health carrier contracts and for ensuring that the requirements of sections 376.1350 to 376.1390
*
and applicable rules and regulations are met.
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(L. 1997 H.B. 335, A.L. 2019 S.B. 514)
*Section 376.1390 does not exist.
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1359 - Written utilization program implemented, filed with the director.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 1997
376.1359. Written utilization program implemented, filed with the director. —
1. A health carrier that conducts utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated, for covered services provided. The program document shall describe information as required by the director.
2. A health carrier shall file an annual report of its utilization review program activities with the director.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1364 - Unique confirmation number required, prior authorization review — secure electronic transmission for prior authorizations — single cover page, contents.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2019
376.1364. Unique confirmation number required, prior authorization review — secure electronic transmission for prior authorizations — single cover page, contents. —
1. Any utilization review entity performing prior authorization review shall provide a unique confirmation number to a provider upon receipt from that provider of a request for prior authorization. Except as otherwise requested by the provider in writing, unique confirmation numbers shall be transmitted or otherwise communicated through the same medium through which the requests for prior authorization were made.
2. No later than January 1, 2021, utilization review entities shall accept and respond to requests for prior authorization of drug benefits through a secure electronic transmission using the National Council for Prescription Drugs SCRIPT Standard Version 2017071 or a backwards-compatible successor adopted by the United States Department of Health and Human Services. For purposes of this subsection, facsimile, proprietary payer portals, and electronic forms shall not be considered electronic transmission.
3. No later than January 1, 2021, utilization review entities shall accept and respond to requests for prior authorization of health care services and mental health services electronically. For purposes of this subsection, facsimile, proprietary payer portals, and electronic forms shall not be considered electronic transmission.
4. No later than January 1, 2021, each health carrier utilizing prior authorization review shall develop a single secure electronic prior authorization cover page for all of its health benefit plans utilizing prior authorization review, which the carrier or its utilization review entity shall use to accept and respond to, and which providers shall use to submit, requests for prior authorization. Such cover page shall include, but not be limited to, fields for patient or enrollee information, referring or requesting provider information, rendering or attending provider information, and required clinical information, and shall be supplemented by additional clinical information as required by the health carrier or utilization review entity.
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(L. 2019 S.B. 514)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1365 - Reconsideration of an adverse determination, when.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 1997
376.1365. Reconsideration of an adverse determination, when. —
1. In a case involving an initial determination or a concurrent review determination, a health carrier shall give the provider rendering the service an opportunity to request on behalf of the enrollee a reconsideration of an adverse determination by the reviewer making the adverse determination.
2. The reconsideration shall occur within one working day of the receipt of the request and shall be conducted between the provider rendering the service and the reviewer who made the adverse determination or a clinical peer designated by the reviewer if the reviewer who made the adverse determination is not available within one working day.
3. If the reconsideration process does not resolve the difference of opinion, the adverse determination may be appealed by the enrollee or the provider on behalf of the enrollee. Reconsideration is not a prerequisite to a standard appeal or an expedited appeal of an adverse determination.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1367 - Emergency services benefit determination, coverage required, when.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2018, 2 histories
376.1367. Emergency services benefit determination, coverage required, when. —
When conducting utilization review or making a benefit determination for emergency services:
(1) A health carrier shall cover emergency services necessary to screen and stabilize an enrollee, as determined by the treating emergency department health care provider, and shall not require prior authorization of such services;
(2) Coverage of emergency services shall be subject to applicable co-payments, coinsurance and deductibles;
(3) Before a health carrier denies payment for an emergency medical service based on the absence of an emergency medical condition, it shall review the enrollee's medical record regarding the emergency medical condition at issue. If a health carrier requests records for a potential denial where emergency services were rendered, the health care provider shall submit the record of the emergency services to the carrier within forty-five processing days, or the claim shall be subject to section 376.383. The health carrier's review of emergency services shall be completed by a board-certified physician licensed under chapter 334 to practice medicine in this state;
(4) When an enrollee receives an emergency service that requires immediate post evaluation or post stabilization services, a health carrier shall provide an authorization decision within sixty minutes of receiving a request; if the authorization decision is not made within sixty minutes, such services shall be deemed approved;
(5) When a patient's health benefit plan does not include or require payment to out-of-network health care providers for emergency services including but not limited to health maintenance organization plans, as defined in section 354.400, or a health benefit plan offered by a health carrier consistent with subdivision (19) of section 376.426, payment for all emergency services as defined in section 376.1350 necessary to screen and stabilize an enrollee shall be paid directly to the health care provider by the health carrier. Additionally, any services authorized by the health carrier for the enrollee once the enrollee is stabilized shall also be paid by the health carrier directly to the health care provider.
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(L. 1997 H.B. 335, A.L. 2018 S.B. 982)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1369 - Certification of compliance, when.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 1997
376.1369. Certification of compliance, when. —
A health carrier shall annually provide a written certification to the director that the utilization review program of the health carrier or its designee complies with all applicable state and federal laws establishing confidentiality and reporting requirements.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1372 - Certification and member handbook to include utilization review procedures — website or provider portal, prior authorization requirements available on.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2019, 2 histories
376.1372. Certification and member handbook to include utilization review procedures — website or provider portal, prior authorization requirements available on. —
1. In the certificate of coverage and the member handbook provided to enrollees, a health carrier shall include a clear and comprehensive description of its utilization review procedures, including the procedures for obtaining review of adverse determinations, and a statement of rights and responsibilities of enrollees with respect to those procedures.
2. A health carrier shall include a summary of its utilization review procedures in material intended for prospective enrollees.
3. A health carrier shall print on its membership cards a toll-free telephone number to call for utilization review decisions.
4. (1) A health carrier or utilization review entity shall make any current prior authorization requirements or restrictions, including written clinical review criteria, readily accessible on its website or provider portal. Requirements and restrictions, including step therapy protocols as such term is defined in section 376.2030, shall be described in detail.
(2) No health carrier or utilization review entity shall amend or implement a new prior authorization requirement or restriction prior to the change being reflected on the carrier or utilization review entity's website or provider portal as specified in subdivision (1) of this subsection.
(3) Health carriers and utilization review entities shall provide participating providers with written or electronic notice of the new or amended requirement not less than sixty days prior to implementing the requirement or restriction.
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(L. 1997 H.B. 335, A.L. 2019 S.B. 514)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1375 - Registry of grievances maintained, procedures — definitions.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 1997
376.1375. Registry of grievances maintained, procedures — definitions. —
1. A health carrier shall maintain a written register of all grievances in a manner consistent with the requirements for maintaining complaint records pursuant to section 354.445. The grievance register shall contain the total number, type, nature and result of all grievances and such other information as may be prescribed by the director. A health carrier shall furnish the director with any records regarding a grievance upon request.
2. All grievances shall be date stamped when received by the health carrier. The date shall be legible and easily identified.
3. Upon receipt of any inquiry from the department of commerce and insurance regarding a grievance, a health carrier shall mail to the department an adequate response to the inquiry within twenty days from the date the department mails the inquiry. An envelope's postmark shall determine the date of mailing. When the requested response is not produced by the health carrier within twenty days, this nonproduction shall be deemed a violation of law, unless the person can demonstrate that there is reasonable justification for that delay. As used in this section:
(1)
"Inquiry"
, each and every question or request for information submitted in writing to a health carrier by the department concerning a grievance;
(2)
"Adequate response"
, a written response answering each inquiry with reasonable specificity. A health carrier's acknowledgment of the department's inquiry is not an adequate response.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1378 - Grievances and certificate of compliance filed with the director, when.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 1997
376.1378. Grievances and certificate of compliance filed with the director, when. —
1. A copy of the grievance procedures, including all forms used to process a grievance, shall be filed with the director. Any subsequent material modifications to the documents also shall be filed. In addition, a health carrier shall file annually with the director, as part of its annual report required by section 376.1375, a certificate of compliance stating that the health carrier has established and maintains, for each of its health benefit plans, grievance procedures that fully comply with the provisions of sections 376.1350 to 376.1390. The director has authority to disapprove a filing that fails to comply with sections 376.1350 to 376.1390 or applicable rules and regulations.
2. A description of the grievance procedure shall be set forth in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage provided to enrollees.
3. The grievance procedure documents shall include a statement of an enrollee's right to contact the director's office for assistance at any time. The statement shall include the toll-free telephone number and address of the department of commerce and insurance.
4. No such grievance procedure shall act as a bar to any suit in a court of competent jurisdiction instituted by any such enrollee, or as a bar to any defense thereto by the health carrier.
5. In the event there is a conflict between the outcomes of the grievance procedure and any such suit, the outcome of the suit in a court of competent jurisdiction shall prevail.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1382 - First- and second-level grievance review for managed care plans, first-level procedures.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 1997
376.1382. First- and second-level grievance review for managed care plans, first-level procedures. —
1. A health carrier that offers managed care plans shall establish a first-level and second-level grievance review process for its managed care plans. A grievance may be submitted by an enrollee, an enrollee's representative or a provider acting on behalf of an enrollee.
2. Upon receipt of a request for first-level grievance review, a health carrier shall:
(1) Acknowledge receipt in writing of the grievance within ten working days;
(2) Conduct a complete investigation of the grievance within twenty working days after receipt of a grievance, unless the investigation cannot be completed within this time. If the investigation cannot be completed within twenty working days after receipt of a grievance, the enrollee shall be notified in writing on or before the twentieth working day and the investigation shall be completed within thirty working days thereafter. The notice shall set forth with specificity the reasons for which additional time is needed for the investigation;
(3) Within five working days after the investigation is completed, have someone not involved in the circumstances giving rise to the grievance or its investigation decide upon the appropriate resolution of the grievance and notify the enrollee in writing of the health carrier's decision regarding the grievance and of the right to file an appeal for a second-level review. The notice shall explain the resolution of the grievance and the right to appeal in terms which are clear and specific;
(4) Within fifteen working days after the investigation is completed, notify the person who submitted the grievance of the carrier's resolution of said grievance.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1385 - Second-level review procedures.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2019, 2 histories
376.1385. Second-level review procedures. —
1. Upon receipt of a request for second-level review, a health carrier shall submit the grievance to a grievance advisory panel consisting of:
(1) Other enrollees; and
(2) Representatives of the health carrier that were not involved in the circumstances giving rise to the grievance or in any subsequent investigation or determination of the grievance.
2. Where the grievance involves an adverse determination, and the grievance advisory panel makes a preliminary decision that the determination should be upheld, the health
*
carrier shall submit the grievance for review to two independent clinical peers in the same or similar specialty as would typically manage the case being reviewed who were not involved in the circumstances giving rise to the grievance or in any subsequent investigation or determination of the grievance. In the event that both independent reviews concur with the grievance advisory panel's preliminary decision, the panel's decision shall stand. In the event that both independent reviewers disagree with the grievance advisory panel's preliminary decision, the initial
**
adverse determination shall be overturned. In the event that one of the two independent reviewers disagrees with the grievance advisory panel's preliminary decision, the panel shall reconvene and make a final decision in its discretion.
3. Review by the grievance advisory panel shall follow the same time frames as a first level review, except as provided for in section 376.1389 if applicable. Any decision of the grievance advisory panel shall include notice of the enrollee's or the health carrier's or plan sponsor's rights to file an appeal with the director's office of the grievance advisory panel's decision. The notice shall contain the toll-free telephone number and address of the director's office.
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(L. 1997 H.B. 335, A.L. 2019 S.B. 514)
*Word "heath" appears in original rolls.
**Word "intitial" appears in original rolls.
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1387 - Appeals of grievances determined by the director.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 1997
376.1387. Appeals of grievances determined by the director. —
1. The director shall resolve any grievance regarding an adverse determination as to covered services appealed by an enrollee or health carrier or plan sponsor through any means not specifically prohibited by law but if the grievance is unresolved by the director then it shall be resolved by referral of such grievance to an independent review organization. The director shall establish the qualifications for such review organizations(s) and shall seek the services of such organization(s) by competitive bid pursuant to chapter 34. The director shall enter into contracts with such organization(s) as deemed necessary to conduct the adverse determination appeals process set forth in this section. Any request for an adverse determination appeal shall be assigned on a rotational basis. The organization's decision as to the resolution of the grievance shall be based upon a review of the written record before it. The grievance and resolution of such grievance shall not be considered a contested case within the meaning of section 536.010, but the resolution of such grievance by the panel shall be considered a final agency decision within the director's discretion, binding upon the enrollee and health carrier, and subject to judicial review if:
(1) Action for such review is filed within thirty days of the final agency decision; and
(2) Judicial review is limited to the record before the director; and
(3) The enrollee and health carrier are deemed real parties in interest; and
(4) The scope of judicial review extends only to a determination of whether the action of the director is unconstitutional, unlawful, unreasonable, arbitrary, or capricious or involves an abuse of discretion or is in excess of the statutory authority or jurisdiction of the director.
2. Nothing in this section is intended to restrict the director's authority to investigate and resolve any complaint against a health carrier that does not constitute a grievance within the meaning of section 376.1350.
3. Any grievance involving coverage provided pursuant to a Medicaid program, however, shall be resolved in accordance with the rules and procedures established for the Medicaid program.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1389 - Expedited grievance review procedure.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 1997
376.1389. Expedited grievance review procedure. —
1. A health carrier shall establish written procedures for the expedited review of a grievance involving a situation where the time frame of the standard grievance procedures set forth in sections 376.1382 and 376.1385 would seriously jeopardize the life or health of an enrollee or would jeopardize the enrollee's ability to regain maximum function. A request for an expedited review may be submitted orally or in writing. However, for purposes of the grievance register requirements in section 376.1375, the request shall not be considered a grievance unless the request is submitted in writing. Expedited review procedures shall be available to an enrollee, the representative of an enrollee and to the provider acting on behalf of an enrollee.
2. A health carrier shall notify an enrollee orally within seventy-two hours after receiving a request for an expedited review of the carrier's determination, and shall provide written confirmation of its decision covering an expedited review within three working days of providing notification of the determination. The provisions of sections 376.1350 to 376.1390 are not applicable to health indemnity plans without a managed care component as defined in 376.1350.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1399 - Rules, effective, when — rules invalid and void, when.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2007
376.1399. Rules, effective, when — rules invalid and void, when. —
Any rule or portion of a rule promulgated pursuant to this act shall become effective only as provided pursuant to chapter 536, including, but not limited to, section 536.028, if applicable, after August 28, 1997. All rulemaking authority delegated prior to August 28, 1997, is of no force and effect and repealed. The provisions of this section are nonseverable and if any of the powers vested with the general assembly pursuant to section 536.028, if applicable, to review, to delay the effective date, or to disapprove and annul a rule or portion of a rule are held unconstitutional or invalid, the purported grant of rulemaking authority and any rule so proposed and contained in the order of rulemaking shall be invalid and void.
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(L. 1997 H.B. 335, A.L. 1997 H.B. 600, et al., § 376.1399 and § 14, A.L. 2007 S.B. 613 Revision)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1400 - Explanation of benefits, standardized information used, contents, when.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
Effective - 28 Aug 1999
376.1400. Explanation of benefits, standardized information used, contents, when. —
1. Every health insurance carrier offering policies of insurance in this state shall use standardized information for the explanation of benefits given to the health care provider whenever a claim is paid or denied. As used in this section, the term "health insurance carrier" shall have the meaning given to "health carrier" in section 376.1350. Nothing in this section shall apply to accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, short-term major medical policies of six months or less duration, other limited benefit health insurance policies.
2. The standardized information shall contain the following:
(1) The name of the insured;
(2) The insured's identification number;
(3) The date of service;
(4) Amount of charge;
(5) Explanation for any denial;
(6) The amount paid;
(7) The patient's full name;
(8) The name and address of the insurer; and
(9) The phone number to contact for questions on explanation of benefits.
3. All health insurance carriers shall use the standard explanation of benefits information after January 1, 2002.
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(L. 1999 H.B. 191)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1403 - Referrals, standardized information used, content, when.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
Effective - 28 Aug 1999
376.1403. Referrals, standardized information used, content, when. —
1. Every health care provider and health carrier that conducts business in this state shall use standardized information for referrals. As used in this section, the terms "health care provider" and "health carrier" shall have the meaning given to such terms in section 376.1350.
2. The referral information shall contain the following:
(1) The name of the insured;
(2) The name, address and phone number of the health carrier;
(3) The identification number and group number of the insured;
(4) The type of referral;
(5) The name, address and phone number of the health care provider referring the insured;
(6) The name, address and phone number of the health care provider to whom the insured was referred to;
(7) The number of visits requested and authorized; and
(8) The health carrier's authorization number.
3. All health care providers and health carriers shall use the standardized referral information after January 1, 2002.
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(L. 1999 H.B. 191 § 376.1406)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1450 - Enrollee's right to receive documents and materials in printed or electronic form, when.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2010, 2 histories
376.1450. Enrollee's right to receive documents and materials in printed or electronic form, when. —
An enrollee, as defined in section 376.1350, may receive documents and materials from a managed care entity in printed or electronic form so long as such documents and materials are readily accessible in printed form upon request. A request by the enrollee may include written, oral, or electronic means. Such requested printed form shall be provided to the enrollee within fifteen business days. For purposes of this section,
"managed care entity"
includes, but is not limited to, a health maintenance organization, preferred provider organization, point of service organization and any other managed health care delivery entity of any type or description.
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(L. 2002 H.B. 1473, A.L. 2010 S.B. 583)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1502 - Requirements for transaction of business.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2007
376.1502. Requirements for transaction of business. —
1. It is unlawful to transact business in this state as a discount medical plan organization, unless the organization is a corporation, limited liability corporation, partnership, limited liability partnership or other legal entity organized under the laws of this state or, if a foreign entity, authorized to transact business in this state, and is registered as a discount medical plan organization with the director or duly authorized by the director as an insurance company, licensed health maintenance organization, licensed group health service organization, or licensed third-party administrator.
2. An individual person, employee, or agent of a registered entity described in subsection 1 of this section may also transact business in this state on behalf of such entity.
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(L. 2007 H.B. 818 merged with S.B. 66)
Effective 8-28-07 (S.B. 66;) 1-01-08 (H.B. 818)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1504 - Registration requirements — term of registration — renewal.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2007
376.1504. Registration requirements — term of registration — renewal. —
1. To register as a discount medical plan organization, an applicant shall:
(1) File with the director an application on a form approved and adopted by the director; and
(2) Pay to the director an application fee of two hundred fifty dollars.
2. A registration is valid for a one-year term and expires one year following the registration date unless it is renewed as provided in this section.
3. Before it expires, a registrant may renew the registration for an additional one-year term if the registrant:
(1) Otherwise is qualified to receive a registration;
(2) Files with the director a renewal application on a form approved and adopted by the director; and
(3) Pays a renewal fee of two hundred fifty dollars.
4. All amounts collected as registration or renewal fees shall be deposited into the insurance dedicated fund.
5. Nothing in this subsection shall require a provider who provides discounts to his or her own patients to obtain and maintain a registration as a discount medical plan organization.
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(L. 2007 H.B. 818 merged with S.B. 66)
Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1506 - Violations, penalty.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2007
376.1506. Violations, penalty. —
1. If the director has a reason to believe that the discount medical plan organization is not complying with the requirements of sections 376.1500 to 376.1532, the director may examine or investigate the business and affairs of any discount medical plan organization under the authority of sections 374.190 and 374.202 to 374.207. The director may require any discount medical plan organization or applicant to produce any records, books, files, advertising and solicitation materials, or other information and may take statements under oath to determine whether the discount medical plan organization or applicant is in violation of the law. Reasonable expenses incurred in conducting any examination shall be paid by the discount medical plan organization under sections 374.202 to 374.207.
2. Failure by the discount medical plan organization to pay the expenses incurred under this subsection shall be grounds for denial or revocation of the discount medical plan organization's registration.
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(L. 2007 H.B. 818 merged with S.B. 66)
Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1508 - Processing fee — cancellation of membership, effect of.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2007
376.1508. Processing fee — cancellation of membership, effect of. —
1. A discount medical plan organization may charge a reasonable one-time processing fee and a periodic charge as long as the fee is disclosed to the applicant.
2. If the member cancels the membership within the first thirty days after receipt of the discount card and other membership materials, the member shall receive a reimbursement of all periodic charges paid. The return of all periodic charges shall be made within thirty days of the date of the cancellation. If all of the periodic charges have not been paid within thirty days, interest shall be assessed and paid on the proceeds at a rate of the treasury bill rate of the preceding calendar year, plus two percentage points.
3. The right of cancellation shall be set out in the written membership materials on the first page, in ten-point type or larger.
4. If a discount medical plan organization cancels a membership for any reason other than nonpayment of charges by the member, the discount medical plan organization shall make a pro rata reimbursement of all periodic charges to the member.
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(L. 2007 H.B. 818 merged with S.B. 66)
Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1510 - Prohibited acts.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2007
376.1510. Prohibited acts. —
A discount medical plan organization shall not:
(1) Use in its advertisements, marketing material, brochures, and discount cards the terms "health plan", "coverage", "co-pay", "co-payments", "preexisting conditions", "guaranteed issue", "premium", "PPO", "preferred provider organization", or other terms in a manner that could reasonably mislead a person to believe that the discount medical plan is health insurance;
(2) Except for hospital services, have restrictions on free access to plan providers including waiting periods and notification periods;
(3) Pay providers any fees for medical services;
(4) Collect or accept money from a member for payment to a provider for specific medical services furnished or to be furnished to the member, unless the organization is licensed by the director to act as an administrator; or
(5) Except as otherwise provided in sections 376.1500 to 376.1532, as a disclaimer of any relationship between discount medical plan benefits and insurance, or as a description of an insurance product connected with a discount medical plan, use in its advertisements, marketing material, brochures, and discount cards the term "insurance".
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(L. 2007 H.B. 818 merged with S.B. 66)
Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1512 - Required disclosures.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2007
376.1512. Required disclosures. —
1. The following disclosures, to be printed in bold and in not less than twelve-point type, shall be made in writing to any prospective member and shall appear on the first page or first content page of any advertisements, marketing materials or brochures relating to a discount medical plan:
(1) The plan is not insurance;
(2) The plan provides discounts with certain health care providers for medical services;
(3) The plan does not make payments directly to the providers of medical services;
(4) The plan member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount plan organization; and
(5) The name and the location of the registered discount medical plan organization, including the current telephone number of the registered discount medical plan organization or other entity responsible for customer service for the plan, if different from the registered discount medical plan organization.
2. If the discount medical plan is sold, marketed, or solicited by telephone, the disclosures required by this section shall be made orally and provided in the initial written materials that describe the benefits under the discount medical plan provided to the prospective or new member.
3. Each discount card or any other plan identifier issued to a plan member shall state in bold and prominent type on the front face of the card that "THIS IS NOT INSURANCE".
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(L. 2007 H.B. 818 merged with S.B. 66)
Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1514 - Written agreement required, contents.

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 28 Aug 2007
376.1514. Written agreement required, contents. —
1. All providers offering medical services to members under a discount medical plan shall provide such services pursuant to a written agreement. The agreement may be entered into directly by the health care provider or by a health care provider network to which the provider belongs if the provider network has contracts with the health care provider that allow the provider network to contract on behalf of the health care provider.
2. A health care provider agreement shall provide the following:
(1) A description of the services and products to be provided at a discount;
(2) The amount or amounts of the discounts or, alternatively, a fee schedule which reflects the health care provider's discounted rates; and
(3) A provision that the health care provider will not charge members more than the discounted rates.
3. A health care provider agreement with a health care provider network shall require that the health care provider network have written agreements with its health care providers that:
(1) Contain the terms described in this subsection;
(2) Authorize the health care provider network to contract with the discount medical plan organization on behalf of the provider; and
(3) Require the network to maintain an up-to-date list of its contracted health care providers and to provide that list on a quarterly basis to the discount medical plan organization.
4. A health care provider agreement between a discount medical plan organization and an entity that contracts with a health care provider network shall require that the entity, in its contract with the health care provider network, require the health care provider network to have written agreements with its providers that comply with subsection 3 of this section.
5. The discount medical plan organization shall maintain a copy of each active health care provider agreement into which it has entered.
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(L. 2007 H.B. 818 merged with S.B. 66)
Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)
2023 Missouri Revised Statutes › Title XXIV - Business and Financial Institutions › Chapter 376 - Life, Health and Accident Insurance › Section 376.1516 - Written membership materials, required contents — forms to be filed with director, fee.

There are multiple enactments of 376.1516
Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS
Chapter 376
• Effective - 01 Jan 2008, 2 histories, see footnote
*376.1516. Written membership materials, required contents — forms to be filed with director, fee. —
1. Each benefit under the discount medical plan and every disclosure required under sections 376.1500 to 376.1532, shall be included in the written membership materials between the discount medical plan organization and the member. The written membership materials shall also include a statement notifying the members of their right to cancel under section 376.1508, and such materials shall also list all of the disclosures required by section 376.1512.
2. All forms used, including written membership materials, shall be filed with the director prior to any sale, marketing or advertising of the discount medical plan in this state. Every form filed shall be identified by a unique form number placed in the lower left corner of each form. A filing fee of twenty-five dollars per form shall be payable to the director for deposit into the insurance dedicated fund.
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(L. 2007 H.B. 818)
Effective 1-01-08
*This section was enacted by H.B. 818 and S.B. 66 during the First Regular Session of the 94th General Assembly, 2007. Due to possible conflict, both versions are printed here.